Comprehensive Clinical Psychology Volume 6

Comprehensive Clinical Psychology
Comprehensive Clinical Psychology. Volume 6
Copyright © 2000 Elsevier Science Ltd. All rights reserved.

Editors-in-Chief: Alan S. Bellack and Michel Hersen
Table of Contents
Volume 6: Adults: Clinical Formulation & Treatment
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Preface
Contributors
6.01 Clinical Formulation, Pages 1-24, Gillian Butler
SummaryPlus | Chapter | PDF (353 K)
6.02 Behavioral Approaches, Pages 25-49, Jürgen Margraf

6.03 Cognitive Therapy, Pages 51-84, Ivy-Marie Blackburn

6.04 Family Therapy and Systemic Approaches, Pages 85-105, Arlene L. Vetere
6.05 Psychodynamic Approaches, Pages 107-134, Peter Fonagy

6.06 Psychopharmacology, Pages 135-161, Philip J. Cowen

6.07 Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches,

Pages 163-181, Larry E. Beutler, Kevin Booker and Stacey Peerson
6.08 Social Skills Training and Problem Solving, Pages 183-201, Kim T. Mueser
6.09 Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis,

Pages 203-227, Graham C. H. Turpin and Michael Heap
6.10 The Therapeutic Relationship, Pages 229-249, Frank M. Dattilio Arthur Freeman and
John Blue
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6.11 Treatment Maintenance and Relapse Prevention, Pages 251-263, John W. Ludgate
6.12 Use of Self-help Books in the Practice of Clinical Psychology, Pages 265-276, Michael
V. Pantalon
6.13 Preventive Goals and Indirect/Consultation Strategies: Meeting Current Needs

Through a Recommitment to Underused Means and Ends, Pages 277-300, Raymond P.
Lorion
6.14 Working with Images in Clinical Psychology, Pages 301-318, Ann Hackmann
6.15 Group Therapy: A Cognitive-behavioral Interactive Approach, Pages 319-337,

Sheldon D. Rose
6.16 Affective Disorders, Pages 339-366, Robert J. Derubeis Paula R. Young and Katherine
K. Dahlsgaard
6.17 Obsessive-compulsive Disorder, Pages 367-398, Gail S. Steketee Randy O. Frost

6.18 Panic Disorder and Agoraphobia, Pages 399-437, Paul M. Salkovskis

6.19 Worry and Generalized Anxiety Disorder, Pages 439-459, Thomas D. Borkovec and
Michelle G. Newman
6.20 Specific Phobias, Pages 461-474, Peter Muris and Harald Merckelbach
6.21 Social Phobia, Pages 475-498, Harlan R. Juster Richard G. Heimberg

6.22 Post-traumatic Stress Disorder, Pages 499-517, Lisa H. Jaycox and Edna B. Foa
6.23 Psychoses: The Management of Severe and Enduring Mental Illness, Pages 519-541,
Geoff Shepherd
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6.24 Somatoform Disorders, Pages 543-565, George H. Eifert and Carl W. Lejuez Theo K.
Bouman
6.25 The Treatment of Substance Abuse and Dependence, Pages 567-585, Robin J.
Davidson
6.26 Cognitive Approach to Understanding and Treating Pathological Gambling, Pages

587-601, Robert Ladouceur Michael Walker
6.27 Sexual Problems: Dysfunction, Pages 603-621, W. P. De Silva

6.28 Relationship Problems, Pages 623-648, W. Kim Halford Howard J. Markman Peter
Fraenkel
6.29 Eating Disorders, Pages 649-667, Anita Jansen

Preface Volume 6
For most clinical psychologists, conducting psychological treatment constitutes the major part of their
day-to-day work. However, the range of problems to be treated and the variety of treatment
approaches available mean that there is remarkably little uniformity in the detail of treatment. Few
would regard psychological treatments as best conducted in a purely prescriptive way, which makes
the issues of treatment integrity and quality control particularly complex ones. The development of
DSM-III (American Psychiatric Association, 1980) confronted clinical psychology with a major
problem. On the one hand, the availability of a reliable classification system appealed to those
committed to a scientific approach to psychology; psychologists had long criticized diagnostic
systems as intrinsically unreliable and therefore having no possibility of any validity, particularly
predictive validity. DSM-III largely dealt with this issue. On the other hand, clinical psychology had
long sought to avoid adopting the "medical model," seeking instead to conceptualize problems in
terms of well-validated psychological processes. One of the first clinical psychologists to articulate
this view clearly was Monte Shapiro, who suggested that the complexity of psychological problems
could best be understood in terms of general psychological processes leading to highly specific
behavioral outcomes.
The most promising solution to the dilemma posed by the widespread adoption of DSM categories in
the context of psychological treatment practice has been the development and adoption of manualized
approaches to treatment. Implicit in this approach is the assumption that diagnostic categories do not
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necessarily "divide nature at the joints," but rather that they represent archetypes which can be
characterized in terms of identifiable (and often interacting) psychological processes involved in the
maintenance of psychological problems. This view suggests that particular problems can be treated
by directly addressing maintenance processes specific to the problem, the person, and the person's
situation. The flexible application of manualized approaches, together with improved training, holds
the promise of more systematic and better quality treatment. This volume of Comprehensive Clinical
Psychology, focusing on treatment in adults, seeks to further that process by providing a reference
source for those wishing to conduct effective psychological therapies of all types.
This perspective highlights one of the major changes which has taken place over the last century in
terms of the way the process of psychological treatment is conceptualized, with the focus of theory
and treatment having moved from identifying and dealing with the origins of psychological problems
to identifying and dealing with those factors involved in the maintenance of such problems. Early
approaches to psychological treatment emphasized the importance of dealing with the causes of
psychological problems. This emphasis reflects the roots of psychiatry and psychotherapy in medical
models, particularly "germ" and "lesion" theories. Early psychiatry was dominated by the discovery
that General Paresis of the Insane, a progressive dementing syndrome which was the most common
reason for admission to lunatic asylums during the nineteenth century, was in fact the result of
tertiary syphilitic infection. Treatment of the syphilis arrested progression of the syndrome. It
logically followed that the task of those seeking to understand and treat other psychiatric syndromes
depended on the identification and effective treatment of the pathogens responsible. A great deal of
psychiatric research conducted since that time has involved seeking the underlying biological or
psychological "pathogen" involved in particular diagnostic categories. This notion remains with us in
various forms. Brain lesion theories abound in psychiatry, fueled by modern brain imaging
techniques which at times resemble a modern variant of phrenology. It appears that some researchers
believe that, if a particular brain area "lights up" more in patients relative to nonpatients, then that
brain area is responsible for the disorder! Hypothesized generalized neurochemical dysfunctions are
another variant of this type of approach. Deficits or excesses in particular neurotransmitters are
hypothesized as likely to be responsible for psychiatric diseases. Such theories are often derived from
the observation that particular diagnostic groups are relatively responsive to some types of
medication and not to others. This reasoning is similar to the idea that because headaches respond to
aspirin, headaches are due to a lack of aspirin. The development of the absurd notion of the
"obsessive-compulsive spectrum disorders" is a good example of this type of reasoning.
How, then, to produce a reference text which characterizes good practice in clinical psychological
treatment without embracing the more negative features and assumptions of medical models? The
solution employed here was to include three types of chapters: on broad approaches and orientations
in psychological treatment, on more general topics which tend to cut across such orientations, and on
particular diagnostic categories.
The Development of Psychological Treatments
There can be little doubt that many modern ideas concerning psychological treatment can be more or
less directly traced to Freud's concept of the "talking cure." More than a century later, treatment not
dissimilar to that advocated by Freud is still practiced as described in Chapter 5 by Fonagy. It is
reassuring to find little evidence in modern psychodynamic approaches of the dogma which led to
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profound schisms within the psychoanalytic establishment earlier in the twentieth century. A major
landmark in the evolution of psychotherapy was the development of humanistic approaches (see
Chapter 7 by Beutler and colleagues). Such approaches have been widely adopted over the past 40
years, with accurate empathy and nonpossessive warmth still being recognized as crucial basic and
enabling ingredients of effective psychological treatment. During the 1950s, Hans Eysenck
highlighted the lack of an empirical basis in psychotherapy, suggesting that it was not possible to rule
out the possibility that the efficacy rates claimed for psychotherapy may be due to spontaneous
remission. This line of argument was extremely influential as behavior therapy emerged in the late
1950s. Joseph Wolpe, the man who effectively founded clinical behavior therapy, adopted a formula
which has since come to dominate scientific psychotherapy. Well-defined theory drives carefully
designed experimental studies into psychological processes involved in psychopathology. The
clinical generalizability of such studies is then evaluated in clinical populations using experimental
designs ranging from intensive experimental investigations of the single case through to controlled
trials evaluating the relative contribution of specific and nonspecific factors. This approach, often
referred to as the "scientist¯practitioner" model, is the mainstay of behavior therapy (described by
Margraf in Chapter 2) and of cognitive and cognitive-behavioral approaches (see Chapter 3 by
Blackburn). Clinical psychology as a discipline has, for many years, been committed to "evidence-
based" approaches of the type embraced, much more recently, by psychiatry. It seems likely that the
clear and unambiguous demonstration of the efficacy of behavioral treatments for anxiety disorders
was crucial in enabling the transition of clinical psychology as a discipline subsidiary to psychiatry,
primarily concerned with testing and psychometric assessment, to a fully-fledged and independent
profession primarily concerned with the management and treatment of psychological disorders.
The more recent addition of "cognitive" to "behavioral psychotherapy" has resulted in a further
remarkable expansion of the problems treated by clinical psychologists and made new techniques
available to clinical psychologists for use with problems such as depression. Drawing upon the earlier
work of George Kelly, Aaron Beck has been particularly influential in developing and elaborating a
theory of emotional problems which draws cognition, affect, and behavior together whilst retaining a
scientific (positivist) stance rather than reverting to earlier introspective approaches which led to so
much criticism of early psychological theories.
In parallel with the development of psychological treatments for psychological problems,

increasingly effective pharmacological treatments have also evolved (see Chapter 6 by Cowen).
Clinically, pharmacological and psychological treatments are often combined, and it seems likely that
it is generally sensible to do this. However, it is clear that pharmacotherapy can be seen by both
patient and clinician as an "easy option." The question of whether there may be long-term interactions
involved in combination treatment is only now beginning to be addressed, and there are early
indications in some disorders that in some instances the combination may result in better outcomes
when compared with pharmacotherapy alone, and worse outcomes when compared with
psychological therapy alone; there is no evidence of the reverse pattern. There is currently some
controversy over the issue of "prescription privileges" for clinical psychologists; it is hard for this
author to see this as anything other than a negative outcome.
Specific Psychological Problems and General Topics
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A substantial proportion of this volume is given over to the consideration of the nature and treatment
of specific problems. As described above, it is not intended to reify diagnostic categories where these
are used, but rather to take these as archetypal examples of particular patterns of psychological
processes and responses. These range from depression (see Chapter 16 by DeRubeis and colleagues)
and anxiety disorders such as social phobia (see Chapter 21 by Heimberg and Juster) and generalised
anxiety disorder (see Chapter 19 by Borkovec and Newman) through to less well-researched
problems such as gambling (see Chapter 26 by Ladouceur and Walker), and so on. In most chapters,
it is again evident that the emphasis is on identifying the key factors involved in the maintenance of
psychological disturbance, with treatment involving helping the sufferer finding ways of dealing with
them. It is an almost universal feature of people who suffer from psychological problems that they
and/or those around them believe that they should "pull themselves together." Those of us who work
with these problems also know that, if they could, our patients would do precisely that. In many of
the problems we work with, our role as clinical psychologists is to help the person find ways of doing
just that. One of the hallmarks of good psychological treatment is the way in which it empowers the
sufferer, implicitly or explicitly providing them with skills to help them to deal better with their
difficulties. Many of the chapters in this volume should help the psychologist to help their patients to
help themselves; in some instances, self-help is the entire focus of interventions (see Chapter 12 by
Pantalon). Many of the skills and much of the knowledge required in the practice of clinical
psychology do not fall into diagnostic categories; indeed, some require a completely different
framework (see Chapter 13 by Lorion).
The chapters in this volume make clear the current strengths of treatment approaches in clinical
psychology. However, complacency is not justified. Outcome research appears to suggest that the
majority of the patients we seek to help get better. However, such research can be misleading. For
example, in obsessive-compulsive disorder (see Chapter 17 by Steketee and Frost), the data suggest
that 75% of patients improve in clinical trials. However, the 75% does not include 25% who refuse
treatment and the 12% who drop out within the first two sessions. Some patients relapse within a
year, and although the most severely disabled may improve substantially, many will remain severely
handicapped at the end of treatment. For most of the problems dealt with in this volume, a similar
pattern holds, and this is also true for pharmacological treatments. The challenge for the next decade
is to improve on this, to make treatments briefer whilst increasing their power, and to reduce relapse
rates (see Chapter 11 by Ludgate). This is a fundamental problem, requiring the development and
implementation of new ideas and approaches. It is my view that the scientist¯practitioner model and
evidence-based approaches will provide the framework required to achieve such goals. It is often
suggested that the other challenge facing clinical psychology is to generalize from research trials to
clinical practice. I believe this to be a "technical" problem which can be solved within the existing
framework, by providing better training and resources.
This volume is ample testimony to the maturity of clinical psychology as a profession with much to
offer in the treatment and prevention of psychological distress. That the bulk of this has been
achieved within the last 30 years is remarkable, and leads one to feel optimistic about the next 30.
Acknowledgments
Many people facilitated the production of this volume. Most of all, my wife, Lorna, and children
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Cora and Duncan have provided motivation and support. My colleague and friend David M. Clark
provides continual inspiration and help, and I owe many things to him. Muriel Lumb and Monika
Juskiewicz gave administrative support and encouragement. Alan Bellack has provided wisdom and
support as needed. My special thanks to Angela Greenwell and David Hoole at Elsevier Science, who
have been unfailingly patient, encouraging, and supportive as I have unfailingly failed to meet their
deadlines.
Volume 6 Contributors
BEUTLER, L. E. (University of California, Santa Barbara, CA, USA)
*Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches
BLACKBURN, I.-M. (Cognitive Therapy Centre, Saint Nicholas Hospital, Newcastle upon Tyne,
UK and University of Durham, UK)
Cognitive Therapy
BLUE, J. (Philadelphia College of Osteopathic Medicine, PA, USA)

*The Therapeutic Relationship
BOOKER, K. (University of California, Santa Barbara, CA, USA)

BORKOVEC, T. D. (Pennsylvania State University, University Park, PA, USA)

*Worry and Generalized Anxiety Disorder
BOUMAN, T. K. (University of Groningen, The Netherlands)

*Somatoform Disorders
BUTLER, G. (University of Oxford, Warneford Hospital, UK)

Clinical Formulation
COWEN, P. J. (University of Oxford, Warneford Hospital, UK)

Psychopharmacology
DAHLSGAARD, K. K. (University of Pennsylvania, Philadelphia, PA, USA)

*Affective Disorders
DATTILIO, F. M. (University of Pennsylvania School of Medicine, Philadelphia, PA, USA)

DAVIDSON, R. J. (Belvoir Park Hospital, Belfast, UK)

The Treatment of Substance Abuse and Dependence
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DE SILVA, W. P. (Institute of Psychiatry, University of London, UK)

Sexual Problems: Dysfunction
DeRUBEIS, R. J. (University of Pennsylvania, Philadelphia, PA, USA)

EIFERT, G. H. (West Virginia University, Morgantown, WV, USA

FOA, E. B. (Allegheny University of the Health Sciences, Philadelphia, PA, USA)

*Post-traumatic Stress Disorder
FONAGY, P. (University College London, UK)

Psychodynamic Approaches
FRAENKEL, P. (New York University, NY, USA)

*Relationship Problems
FREEMAN, A. (Philadelphia College of Osteopathic Medicine, PA, USA)

FROST, R. O. (Smith College, Northampton, MA, USA)

*Obsessive-compulsive Disorder
HACKMANN, A. (University of Oxford, Warneford Hospital, UK)

Working with Images in Clinical Psychology
HALFORD, W. K. (Griffith University, Nathan, Qld, Australia)

HEAP, M. (University of Sheffield, UK)

*Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis
HEIMBERG, R. G. (Temple University, Philadelphia, PA, USA)

*Social Phobia
JANSEN, A. (Universiteit Maastricht, The Netherlands)

Eating Disorders
JAYCOX, L. H. (Allegheny University of the Health Sciences, Philadelphia, PA, USA and RAND,
Santa Monica, CA, USA)
*Post-traumatic Stress Disorder
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JUSTER, H. R. (Pine Bush Mental Health, Albany, NY, USA)

*Social Phobia
LADOUCEUR, R. (Universit•aval, Qu c, PQ, Canada)

*Cognitive Approach to Understanding and Treating Pathological Gambling
LEJUEZ, C. W. (West Virginia University, Morgantown, WV, USA)

LORION, R. P. (Ohio University, Athens, OH, USA)

Preventive Goals and Indirect/Consultation Strategies: Meeting Current Needs Through a
Recommitment to Underused Means and Ends
LUDGATE, J. W. (Bristol Regional Medical Center, Bristol, TN, USA)

Treatment Maintenance and Relapse Prevention
MARGRAF, J. (Technische Universit•Dresden, Germany)

Behavioral Approaches
MARKMAN, H. J. (University of Denver, CO, USA)

MERCKELBACH, H. (University of Maastricht, The Netherlands)

*Specific Phobias
MUESER, K. T. (New Hampshire–Dartmouth Psychiatric Research Center, Concord, NH, USA)

Social Skills Training and Problem Solving
MURIS, P. (University of Maastricht, The Netherlands

*Specific Phobias
NEWMAN, M. G. (Pennsylvania State University, University Park, PA, USA)

*Worry and Generalized Anxiety Disorder
PANTALON, M. V. (Yale University School of Medicine, New Haven, CT, USA)

Use of Self-help Books in the Practice of Clinical Psychology
PEERSON, S. (University of California, Santa Barbara, CA, USA)

ROSE, S. D. (University of Wisconsin–Madison, WI, USA)

Group Therapy: A Cognitive-behavioral Interactive Approach
SALKOVSKIS, P. M. (University of Oxford, Warneford Hospital, UK)
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Panic Disorder and Agoraphobia
SHEPHERD, G. (Health Advisory Service (HAS 2000), London, UK)

Psychoses: The Management of Severe and Enduring Mental Illness
STEKETEE, G. S. (Boston University, MA, USA)

*Obsessive-compulsive Disorder
TURPIN, G. C. H. (University of Sheffield, UK)

*Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis
VETERE, A. L. (University of Reading, UK)

Family Therapy and Systemic Approaches
WALKER, M. (University of Sydney, NSW, Australia)

*Cognitive Approach to Understanding and Treating Pathological Gambling
YOUNG, P. R. (University of Pennsylvania, Philadelphia, PA, USA)

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6.01
Clinical Formulation
GILLIAN BUTLER
University of Oxford, Warneford Hospital, UK
6.01.1 INTRODUCTION 1
6.01.2 DEFINITIONS: WHAT IS A FORMULATION? 2
6.01.2.1 Main Principles 2
6.01.2.2 Formulation and Diagnosis: Assumptions 4
6.01.2.3 Formulation and Diagnosis: Controversial Issues 5
6.01.2.4 The Difference Between a Formulation and a Model 6
6.01.2.5 Types of Formulation 7
6.01.2.6 Levels of Formulation 7
6.01.3 PURPOSES: WHAT A FORMULATION IS FOR 8
6.01.3.1 Understanding: The Overall Picture or Map 9
6.01.3.2 Prioritizing Issues and Problems 9
6.01.3.3 Planning and Selecting Intervention Strategies 10
6.01.3.4 Predicting Responses and Difficulties 10
6.01.3.5 Determining Criteria for Successful Outcome 11
6.01.3.6 Thinking About Lack of Progress 11
6.01.4 METHODS: HOW TO CONSTRUCT A FORMULATION 12
6.01.4.1 Sources of Information 12
6.01.4.2 Putting the Information Together 14
6.01.4.3 Key Factors and Basic Elements 17
6.01.4.4 Issue of Completeness 18
6.01.4.5 Conceptualizing Processes of Change 19
6.01.5 ACCURACY: HOW TO TELL IF A FORMULATION IS RIGHT 20
6.01.5.1 Criteria of Accuracy 20
6.01.5.2 Questions for Research 20
6.01.6 USING THE FORMULATION: PRACTICAL ISSUES 21
6.01.6.1 The Value of Organizing and Clarifying 21
6.01.6.2 Developing an Internal Supervisor 21
6.01.6.3 Communicating a Formulation 22
6.01.7 CONCLUDING DISCUSSION 22
6.01.8 REFERENCES 23
6.01.1 INTRODUCTION thereby enabling the patient to regain his morale.

(Frank, 1986)
Patients come to psychotherapy because they are

demoralized by the menacing meanings of their Although not all therapists would be happy
symptoms. The psychotherapist collaborates with with the idea that they are ªformulating a
the patient in formulating a plausible story that plausible story,º the process of clinical formula-
makes the meanings of the symptoms more benign tion remains the lynch pin that holds theory and
and provides procedures for combatting them, practice together. This is agreed by proponents
1
2 Clinical Formulation
of most major therapeutic traditions: for exam- of marrying theory and practice is therefore
ple, behavior therapy (Turkat & Maisto, 1985; fraught with difficulty. As well as having
Wolpe & Turkat, 1985), psychodynamic therapy different reasons for requesting psychological
(Barber & Crits-Christoph, 1993; Perry, Cooper, help, people vary in their ability to describe or
& Michels, 1987; Silberschatz, Fretter, & Curtis, name their difficulties, in their histories and
1986), family therapy (Minuchin, 1974), cogni- relationships with their families, friends and
tive therapy (Freeman, 1992; Persons, 1989, colleagues, in their ability to relate to a therapist,
1993), cognitive analytic therapy (Ryle, 1978, degree of psychological-mindedness, and emo-
1990), and interpersonal therapy (Klerman, tional expressiveness. As well as having different
Weissman, Rounsaville, & Chevron, 1984). theories, training, and clinical experience, thera-
The attempt to construct and use a clinical pists vary in the ways in which they understand,
formulation is central to the work of therapy. communicate with, and relate to their patients.
Various methods for systematizing the processes Therapists bring with them to therapy specific
involved have recently been proposed (Horo- skills, expertise, and information, and also their
witz, 1989; Luborsky & Crits-Christoph, 1990) individual personalities and inclinations. The
and, thinking specifically about the issues in- process of formulation is influenced by all these
volved in psychotherapy integration, Goldfried disparate factors, and this makes learning how to
(1995) has put forward a case for developing a formulate a case with the necessary objectivity,
common language for case formulation that is clarity, and attention to the individual to guide a
independent of theoretical orientation. Personal successful treatment one of the most fascinating,
discussions of many kinds may be more or less rewarding, and difficult tasks faced by clinicians.
valued and helpful to someone experiencing a The assumption that many clinicians of
difficulty, including the informal advice traded different orientations probably share about
between friends, but one of the major differences the psychological difficulties of others is this:
between informal discussions and responsible at some level it all makes sense. Even though our
clinical practice is that they do not make use of understanding of the processes involved, and
the process of formulation. The attempt to particularly of their inter-relationships, is in-
formulate a case, so as to apply an appropriately complete, this assumption was given a simple,
chosen method of intervention in the light of a and relatively uncontroversial, diagrammatic
particular theory, is one of the activities that form by Padesky and Mooney (1990). The
makes therapists, as opposed to friends, accoun- difficulties that people describe to their thera-
table for their practice. pists have four inter-related aspects (cognitive,
This chapter discusses issues concerning affective, behavioral, and physiological), and
clinical formulation that are relevant to thera- change in any one of these variables affects all of
pists from different theoretical backgrounds. the others, as shown by the bidirectional arrows
However, the illustrations of the general points in Figure 1. So, taking anxiolytic medication can
made will largely be drawn from the author's make one feel calmer, think about problems
own experience and will therefore reflect the more constructively, and do some of the things
author's original cognitive-behavioral training, that previously seemed too difficult or over-
together with a more recent interest in exploring whelming. Feeling more cheerful can lighten
possibilities for integration between different ones step, help one to feel more optimistic, and
kinds of psychotherapy. relate more productively to others. Changing
ones perspectiveÐor way of thinkingÐcan
provide the sort of new outlook that helps to
6.01.2 DEFINITIONS: WHAT IS A dissipate distress, reduce tension, and encourage
FORMULATION? constructive activity, and so on. The four ways in
6.01.2.1 Main Principles which aspects of psychological life are conven-
tionally categorized reflect the internal workings
A formulation is the tool used by clinicians to and psychological state of a person at a
relate theory to practice. Clinicians use theor- particular point in time. This person is at the
etical as well as practical knowledge to guide same time relating to the external world through
their thinking about the problems and difficul- a personal social, political, and historical
ties presented by the people who come to them context. The factors that determine this context,
for help, and this combination of ideas helps and fashioned it to be the way that it now is, are
them decide how best to help those people. not easy for psychological therapists to know
However, although the theories are relatively about: hypotheses for explaining and under-
simple and clearÐadmittedly to varying standing the way they interact with each of the
degreesÐthe information brought to treatment, four types of phenomena have been made. The
and gathered during the process of assessment, is overall configuration is the source of the
always complex and often unclear. The process narrative, or story, that a person brings to
Definitions: What is a Formulation? 3
therapy. If we understood the rules governing between the two people involved in therapyÐ
the relationships between all these factors we methods which were originally described and
would, no doubt, be better able to help our understood by proponents of the various
patients. psychodynamic schools of therapy. Interperso-
The business of therapy, to a large extent, nal therapy and systems therapy also formulate
involves intervening to facilitate change in (at problems in terms of relationships between the
least) one of the four main aspects of psycho- person requesting help and others around them,
logical life shown in Figure 1, and different and use this understanding to help people
kinds of therapy attend differently to these change as they wish. All of these methods
different aspects, entering the process of change initiate the process of change in different ways,
through different gateways. The intention, determined by the way in which they under-
however, is much the sameÐto help people stand, or formulate, the problem presented, and
solve the problem or problems that they bring to it is this understanding that determines what
therapy. Pharmacological and traditional be- therapists doÐwhat steps they take to alleviate
havioral therapies provide perhaps the clearest the problem.
examples as the methods that they use, and the The point is that the way in which a
formulations upon which these methods are formulation is constructed will be influenced
based, can be isolated relatively easily. Cogni- by the point at which a therapist enters, and
tive therapies, which adopt both cognitive and attempts to influence, this dynamic relationship
behavioral methods, operate on at least two between these main aspects of psychological
levels. They may concentrate on identifying and life. Some general points are important:
reexamining particular thoughts, thereby chan- (i) each aspect influences all of the others, so
ging feelings and behavior, and/or they may none of the therapies has the exclusive aim of
focus on underlying meanings and beliefs and changing one factor. Rather, by focusing the
adopt more sophisticated and complex methods process of change in one place, the aim is to
of intervention, often related to those used in bring about the change that the patient
more dynamic and experiential traditions. desiresÐusually to ªfeel better,º in all the
Experiential therapies make specialized use of relevant respects.
the medium provided by the feelings and (ii) The main medium of therapy is
thoughts arising in the present context of languageÐwhat one person says or suggests,
therapy, and work with these to facilitate a to another. To this extent, the cognitive, im-
dynamic process of change. In order to do this, plicational context within which therapies take
it becomes essential to think about, and to place provides the basis for the way in which the
formulate, what happens in the relationship presenting problems will be formulated.
Cognition
The
environment:
personal,social,
historical
context,
etc.
Affect Physiology
Behavior
Figure 1 Inter-relationships between aspects of functioning (Padesky & Mooney, 1990).

(iii) Understanding of other people, and formulation is made. At this point it is probably
hence the ability accurately to formulate their sufficient to enunciate one of the principles that
problems, develops within the context of the will run through this chapterÐthat of parsi-
relationship between them, mediated by factors mony. In principle, it is always better, and more
such as trust and acceptance as well as by useful, to keep the formulation as simple as
language. possible. The temptation to elaborate a for-
(iv) Our understanding of the ways in which mulation is strong, especially when dealing with
the aspects of psychological life are integrated is complex cases. However, the simpler and clearer
partial. At this point in time, psychology is an it is the more readily will its implications be seen
imperfect but developing science. The implica- and the easier it will be to use.
tion of this is that formulations for the purpose Theoretically speaking, the principles that
of therapy have to be speculative. guide the practice of formulation are derived
Formulations can best be understood as from the way in which the concept is defined.
hypotheses to be tested, and the most obvious, The three main ones to be proposed here are:
if not the most logical, test of a formulation will (i) A formulation should be based on a
be the response to the selected interventions. theory, reflecting an attempt to put the theory
This is not to say that an expected change into practice.
following a specific intervention proves that the (ii) A formulation should be hypothetical in
formulation on which it was based is accurate. nature, so that it can be modified by informa-
Unfortunately, the reasons why change occurs tion gained during the course of treatment.
are far more complex and difficult to discern (iii) A formulation should be as parsimo-
than this. However, the formulation used in this nious as possible.
way is perhaps the main tool that the therapist
has from which to draw such conclusions in the
individual case. Thus, working in an open- 6.01.2.2 Formulation and Diagnosis:
minded way with a formulation provides a Assumptions
means of contributing as a therapist to the
scientific endeavor involved in finding out In psychological practice there appears to be
which are the best, most effective, and most a common assumption that only those patients
efficient, methods of treatment. who participate in research trials have simple
Although a formulation provides the link diagnoses, for example, of the kinds defined in
between theory and practice, it does so at a the various versions of the DSM. Diagnostic
different level of generality. A theory is the systems are useful for ensuring that the
source of general explanations and general populations studied in different places are
hypotheses, whereas a formulation is specific to similar in the relevant respects, and they are
the person to whom it applies, and therefore is useful for insurance purposes, but from the
the source of more specific explanations and point of view of the therapist they have
hypotheses. The specificity of the formulation is limitations in that they rarely provide specific
the source of ideas about the selection of specific implications for treatment. Besides, unselected
interventions and about how to adapt them for samples of patients often do not have single,
use with a particular person. It is for these clear problemsÐindeed informally they are
reasons that Wolpe and Turkat (1985) describe commonly said to ªfulfill criteria for an average
a formulation as a theoretically guided way of of 2.3 diagnoses.º A formulation, however, is
structuring the information concerning a pa- designed precisely to fit the individual and is
tient's problem. It reflects the product of taking intended to help therapists to derive
an individual approach to clinical phenomena theoretically-based hypotheses about factors
and combining this with knowledge of relevant that contribute to causing and maintaining their
theories, scientific principles, and research specific problemsÐto explain as well as to
findings. It involves imposing an explanatory describe. Therefore, the argument runs, diag-
system upon the material presented, and raises noses are less useful than formulations, from
questions concerning the degree to which this which specific treatment implications can be
explanatory system should reflect every aspect derived, and they may be less necessary than
of a problem. One view is that it should reflect formulations. For example, one depressed
everything, including a patient's past develop- person's sense of failure may be triggered by
ment, characteristic ways of behaving and an inability to live up to exacting standards and
forming relationships, emotions, beliefs, as- another person's by an inability to form close
sumptions, attitudes, self-evaluations, expecta- relationships (for any number of reasons, which
tions, attributions, appraisals, and so on. In may be discovered during therapy and included
practice, the degree of elaboration required in the formulation). Only having the diagnosis
depends upon the purpose for which the tells the therapist nothing about this difference,
and ignoring the difference will reduce the ness and poor self-esteem may be relevant in
chances of achieving a satisfactory outcome. both cases, so the assessment which provides an
This argument has much to recommend it to adequate basis for a formulation, and for a
the therapist, especially as diagnoses are largely specific treatment plan, must cover more than
atheoretical descriptions, and therapists can use the criteria for inclusion and exclusion that
their theoretical knowledge to construct for- determine whether or not someone qualifies for
mulations that are clinically useful. This does a diagnosis.
not mean thinking anew with each patient, but
keeping in close touch with theoretical and
clinical research so that, for example, empiri- 6.01.2.3 Formulation and Diagnosis:
cally validated treatments can be selected when Controversial Issues
the diagnosis suggests they would be appro-
priate, and individual formulations then used to The assumption behind the argument pre-
specify details of their application. Learning to sented above is that a treatment plan based on a
work with a formulation instead of relying on a formulation will have a better chance of success
diagnosis also has advantages when the pro- than one based on a diagnosis. However, there is
blems presented are unusually rare or complex considerable debate about this issue, and some
and do not fit readily into a diagnostic system, recent research suggests that the assumption
or when the system does not succeed in ªcarving could be false. Schulte, KuÈnzel, Pepping, and
nature at the joints,º and the demarcation Schulte-Bahrenberg (1992) and Schulte (1997)
between one diagnosis and another is difficult to found that patients with phobias, assigned to a
establish. Of course there are difficulties with standardized treatment (exposure in vivo) on the
this point of view. Seen from the patient's basis of their diagnoses, responded at least as
perspective, over-reliance on the process of well as, and possibly better than, patients whose
formulation may involve a degree of risk. treatments had been selected on the basis of
What if the theory is wrong? Or if the therapist individual problem analyses. With this finding
is unclear about it? Or susceptible to bias? Or in mind, Wilson (1996, 1997) summarized the
unable to come up with an adequate formula- arguments for using manual-based, empirically-
tion? Or attempts to combine one theory with validated treatments, also selected on the basis
another without understanding sufficiently well of diagnoses, and argued that there are inherent
the implications of doing soÐas when borrow- limitations involved in basing treatment on
ing from experiential or dynamic ideas when idiographic case formulation. As he points out,
doing cognitive therapy for instance? This risk making formulations involves making judg-
can be reduced by formalizing the requirements ments and judgments are fallible. They are
of responsible clinical practiceÐby providing demonstrably susceptible to bias and using
adequate training and supervision, by clarifying them introduces an additional source of error. It
ethical guidelines, and by defining criteria for would be better, he argues, to adopt an actuarial
professional accountability, including the ex- approach to assessment and treatment as this is
pectation that practitioners will keep in touch more likely to result in a superior outcome than
with the literature relevant to their practice. using clinical judgment, at least when treatment
Ultimately though, the mysterious faculty of manuals are available.
clinical judgment has also to be brought into The issue is complex (Beutler, Williams,
play. Without thisÐwhatever it isÐclinicians Wakefield & Entwistle 1995; Hayes, Follette,
may well run into difficulties, both making and Risley, Dawes & Grady, 1995; Norcross,
using formulations. Alford, & DeMichele, 1992; Seligman, 1995;
The implication of this argument is primarily Stricker & Trierweiler, 1995), and differences
that, much of the time, formulations are more will not be settled here. Nevertheless, it is useful
useful than diagnoses, provided that therapists to clarify the basis of the disagreement, as two
are well versed in the theories they are using, and issues are frequently confounded. The first
that diagnoses, which can after all convey a concerns the failure of practicing clinicians to
large amount of information in a few words, adopt standardized practices and the second
may help to streamline the process of assess- concerns the dangers of over-reliance on
ment, and may guide decisions about treatment individual formulations. Those who argue
in relatively straightforward cases. For exam- against the use of formulations seem to forget
ple, knowing someone is socially phobic directs that it is the job of practicing clinicians to bridge
attention towards a fear of being humiliated or the gap between science and practice, and in
embarrassed, and knowing the diagnosis is of doing so to balance the requirements of
bulimia nervosa focuses attention on over- recommended procedures with clinical flexibil-
concern with shape and weight (among other ity. A formulation, as defined above, is intended
things). Underlying problems of self-conscious- to facilitate this processÐto assist the clinician
in adapting the procedure to the particular on theories. They may or may not be subject to
circumstances. When treatments so adapted are the same disadvantages as labels. Formulations
reported to be less effective than expected, then differ in that they bring together the products of
many factors in addition to formulation could theoretical knowledge and clinical judgment.
contribute to this finding. These include the Their theoretical basis reflects ideas about the
quality, integrity, structure, and delivery of the factors that cause and maintain problems, and
treatment, the accuracy with which the effects of that precipitate or prolong particular episodes
treatment can be measured, and the relevance of of distress. This theoretical basis provides a
the measures used to the outcome desired by the framework for the type of personal, individual
patient. Proponents of the view that treatments formulation on which precise decisions about
can be selected on the basis of diagnoses alone treatment can be based. Their advantages and
seem to assume that case formulation is disadvantages are discussed further below.
idiographic, in the sense that making one is
unconstrained by theoretical ideas and using it
to select interventions is independent of the 6.01.2.4 The Difference Between a Formulation
findings of clinical research. and a Model
Neither of these points is accepted here.
Instead it is argued that individual case Models are ways of conceptualizing particu-
formulation is always relevant, even when lar disorders (e.g., the cognitive hypotheses of
applying a manual-based treatment (examples obsessive-compulsive disorder and of health
will be found below). It is also argued that anxiety described by Salkovskis (1996), or of
formulations have to be rooted in theory to be formulating particular patterns of functioning
useful, and that using clinical judgment is not (e.g., the role±relationship models developed by
providing a licence for subjectivity, but recog- Horowitz, Eells, Singer and Salovey (1995) or
nizing that at least some of the time clinicians will the functional analytic causal model of Haynes,
not be able to follow the rule book, even when Uchigakiuchi, Meyer, Orimoto, and Blaine
there is one. Then they have to use their (1993). Models, as understood here, are con-
judgment. In doing so, they can appeal to many structed from a particular perspective, so there
sources of understanding, including theories are separate cognitive models of panic disorder
about psychological dysfunction, and their (Clark, 1988) and social phobia (Clark & Wells,
knowledge of the relevant literature. As Stricker 1995), and the psychopharmacological or
and Trierweiler (1995, p. 997) put it ªit is likely interpersonal psychotherapy models of panic
that the practitioner always will be required disorder differ from the cognitive model. These
to go beyond firm and available scientific differences are valuable in that they stimulate
knowledgeºÐless so when treating phobias useful research, as well as the development of
than when treating a complex of depression and sets of coherent treatment strategies. Using the
anxiety in someone with a dependent person- cognitive model of panic disorder as an
ality type, and not without keeping in touch example, this would suggest that catastrophic
with scientific advanceÐbut individual judg- misinterpretation of bodily symptoms plays a
ment and case formulation remain indispensa- crucial role in triggering panic attacks, and that
ble clinical tools. Using these tools does not understanding this will help people who suffer
exempt the practitioner from being aware of the from panic disorder to identify the symptoms
pitfalls of basing decisions about treatment on that trigger their panics. They will then be in a
anecdotal case material, intuition, or subjective position to think again about the meaning of
impression. On the contrary, working with a these symptoms, and to reinterpret them in
formulation that can be explained to others terms of (harmless but distressing) panic rather
provides a check on the use of too much specu- than of real, impending catastrophe. In order to
lation and too many far-fetched inferences. facilitate the therapeutic process, the model has
Therapists need to speak about their patients' to be translated into a conceptualization (or
problems in many settings and contexts, and to formulation), and structured systems for doing
do so can make use of any of the available this can be developed, as in this case has been
systemsÐlabels, diagnoses, descriptions, and done by Dattilio (1994). So the model provides
formulations. Labels (e.g., manipulative, hys- guidelines for an individual formulation which
terical, narcissistic, personality disordered) are encourages a new explanationÐthe leap in my
efficient but can bring assumptions with them heart could be a response to the coffee I have
(and in these examples, assumptions that may just drunk, or a normal arrhythmia that I notice
not be to the advantage of the person being more readily than I used to because it frightens
labeled). Diagnoses reflect agreed systems of me, and not a sign of imminent cardiac crisis.
categorization and for the most part are based Although a model has implications for
on particular kinds of descriptions rather than treatment, it differs from a formulation in that
it operates at a different level of generality, and 6.01.2.5 Types of Formulation

has a different content. So, the way in which a
formulation applies to particular people will Typically, different therapeutic schools are
depend upon their personal history and circum- thought to use different types of formulation. In
stances. One person's panic may be triggered by general, behavioral and cognitive therapies
leaps in the heart and another's by losing make use of more mechanistic formulations,
concentration when being spoken to (and a based on theories about learning and detailed
third may find that memories of traumatic functional analysis (Hayes & Follette, 1992), or
incidents, flashbacks, or nightmares precipitate on theories about processes such as the
panic, possibly because they trigger associated supposedly circular relationships between
sensations that then trigger the panic attacks). thoughts and feelings, and more dynamic
There will in practice always be exceptions to therapies employ more narrative-based formu-
the rule, cases in which, for example, no lations, placing current problems in the context
sensational trigger can be identified. Then the of a developmental history. Some systemic and
clinician may be best advised to base the experiential approaches to therapy adopt a
formulation on a higher level theory rather third, essentially dynamic, approach, claiming
than on the specific modelÐin this case on the that formulations have constantly to be re-
general theory that cognitions, including mean- formed in the present, as therapy focuses on
ings, are closely related to feelings and behavior, moment-to-moment events (Goldman &
and that changing one is likely to change the Greenberg, 1997). They also point out that
others. Thus the formulation illustrates, in ways the process of formulation can be dangerous
that are clinically relevant, how the model and limiting when it makes use of preset
applies, and does not apply, to the case. It assists categories and ideas. A constantly changing
the therapist in looking for particular theore- situation then appears to be fixed, and
tical constructs or processes (catastrophic opportunities for change may be obscured
misinterpretations in this example), and also (Eells, 1996; Rosenbaum, 1996). However, the
in making a judgment about the degree to which process of formulation is still thought to be
the case is typical. essential, and its main purpose is still to look for
Atypical cases arise when patients have more patterns and links that assist in understanding,
than one difficultyÐsocial anxiety as well as and to provide ideas about how to bring about
panic disorder for exampleÐor when they have change. So, distinctions can be applied too
especially complex or rare problems such as rigidly. The developmental history of a problem
panic attacks in the context of avoidant or or a person, or the narrative, is always relevant
borderline personality disorder. Then, concep- (Nicholson, 1995; White, 1989), although it may
tually speaking, it may be more useful to draw be understood in different ways, and so are ideas
on more than one model to construct a single about the mechanisms that precipitate an
formulation, or to look for models with a higher episode of distress or perpetuate a problem.
order of generality. Writing about psychody- Overt differences between types of formulation
namic formulation, Perry et al. (1987) point out are therefore relatively unimportant to an
that overlapping models of mental functioning understanding of the term, and of the functions
may emphasize different aspects of develop- that the activity of formulating a case performs
ment and psychopathology. They distinguish for the therapist.
ego-psychological, self-psychological, and ob-
ject relations models, and make the important
point that a certain amount of trial and error 6.01.2.6 Levels of Formulation
may be needed in constructing a formulation
that explains the presenting data: ªthe absence When making a formulation, it is necessary to
of a meta-model to explain all data makes this think at many different levels, and the number
trial and error unavoidableº (p. 546). What of levels postulated obviously varies with the
clinicians are looking for in a formulation is a theory being applied. Taking an example from
way of explaining and understanding the cognitive-behavioural therapy (CBT) to illus-
relationship between a patients' inner lives trate the point, at the most superficial level, or
and their outer lives that is the product of their the level of ªovert difficultiesº (Persons, 1989),
personal history, explains present difficulties, the main task is to define the problems and the
and guides future therapy. Their sources in this ways in which they are maintained, usually in
search include knowledge of diagnostic systems, terms of vicious cycles. Someone who feels
of relevant theoretical models, and of outcome depressed may withdraw from company, think
research, as well as information about the about being all alone, and become increasingly
individual caseÐotherwise they would have to depressed. Even such a simple formulation
reinvent the wheel each time. suggests a focus for interventionÐworking to
reduce the withdrawal. Thinking about the Formulations are always made from a
factors that precipitated the depression adds particular perspectiveÐin the author's case
another level to the formulation. The person made (usually) from a cognitive-behavioral
might have become depressed when their job perspective, and from that of a White woman
required them to move to a new place, when of a certain age, living in Britain now, whose
they got divorced, or when their children left ways of thinking have been formed by her own
homeÐfactors that would demand different learning and experience. A formulation is
types of adaptation, to be promoted by the neither about fitting information about a
therapist in different ways. Stressors are patient to a predetermined formula, whether
additive, so many factors may be involved, that formula be derived from a general theory or
and an apparently minor stressor may be the from a more specific model, nor is it a personal
straw that broke the camel's back (and relatively judgment, though both things are relevant. It is
irrelevant to the formulation), or it may reflect a about developing the kind of understanding of
particular personal vulnerability. Factors that another person, their circumstances and their
predispose someone to become depressed, difficulties, that enables a therapist to apply the
biological as well as psychological factors, theoretical knowledge acquired during training
add a further level, and the way in which these to help that person. There is no single right way
are understood, and formulated, will again of making a formulation. The general aim is to
influence the selection of interventions. At the map the territory so that one can then explore
most profound level of all, assuming that ªat the possibilities for change, and not to let these
some level it all makes sense,º the formulation is be influenced by factors that are irrelevant to, or
supposedly capable of reflecting the meaning of unwanted by, the person who is receiving help.
structures through which people interpret and
think about, remember and recount, their
experiences, and theoretical assumptions about 6.01.3 PURPOSES: WHAT A
the origin of these things. FORMULATION IS FOR
This is the standard way in which psychiatric
formulations have traditionally been madeÐin One common view of the purpose of
terms mainly of predisposing, precipitating, and formulation is that it is for explaining the past,
perpetuating factors. However, there are yet making sense of the present, and suggesting
other levels to consider, reflecting social, what to modify in order to influence the future.
cultural, and historical factors. Social assump- It can also be an important means of commu-
tions (ªmen should not show their feelingsº or nicating understanding, either to the patient or
ªwomen are bad organizersº) influence the to another professional, whether in the role of
views of therapists as well as patients, and supervisor or colleague. However, its prime
cultural assumptions may or may not be shared purpose is to help therapists to apply the theory
between therapist and patient. Some cultures, they have learned to their practice (a compre-
for example, do not share the common Western hensive account of different approaches to
therapeutic goal of autonomy, especially for formulation is given by Eells (1997).
women. Others assume that a relationship In practice, there are many answers to the
between a professional person and their client question ªWhat is a formulation for?º The main
is one involving activityÐor authoritative functions of formulation are listed in Table 1.
pronouncementsÐon the one side, and The main point is that making formulations is
passivityÐor receptivityÐon the other. In an essential, and not an optional, element of the
addition, different hierarchies of values can therapeutic process. Formulations do not have
interfere profoundly with the therapeutic pro- to be 100% accurate or complete in order to be
cess. An example in our culture is when someone useful precisely because they provide a source of
thinks it more important to avoid giving offence testable hypotheses. They can be changed when
than it is to tell the truth. Although it is never they turn out to be wrongÐand nothing is lost
possible to stand outside all of these factors, by using a partial or partially mistaken
making a formulation helps therapists to think formulation which can be improved and
about them, to identify them clearly, and to corrected as the process of therapy continues,
become aware of their potential influence on the and reveals the initial mistake. They guide
interpretation of other people's circumstances. questioning, and open the therapist's mind to
It can help therapists to ensure that the ways in the kind of understanding from which effective
which they understand problems and select treatment strategies can be derived, applied, and
interventions are not influenced by unwanted evaluated. Therefore, the author would argue,
biases. Seen in this way, a formulation assists that therapists should work with a formulation
therapists in achieving a relatively objective in mind right from the start. Ideas about people
stance. and their problems cannot be kept at bay or
Purposes: What a Formulation is for 9
excluded, even when first meeting them or therapy unless they can see the point of it.
reading a referral letter about them. One way of Creating hope, or the context for a developing
trying to ensure that this information is openly relationshipÐsomething with a future, in which
received and accurately assessed is to engage change is inherent and undeniableÐthen be-
immediately in the process of formulationÐin comes a priority. Likewise, an initial assessment
applying both theoretical and clinical knowl- may indicate primarily that inability to trust
edge to the particular case. Just as when first people will make it hard to disclose distressing
visiting a new place, a rough sketch map may set material, and building trust within the ther-
one on the right road at first, but will need apeutic relationship is necessary before a more
expanding and revising if it is to guide more detailed and accurate formulation can be made.
detailed exploration. It is probably not unusual for patients and
therapists to start the process of therapy with
somewhat different priorities. Usually this
6.01.3.1 Understanding: The Overall Picture or problem can be overcome during assessment
Map and those early stages of therapy during which
goals become clear or are specifically agreed. But
A formulation ªprovides the map of the
sometimes different priorities persist, and then
territory and once you have that you can use
the process of re-formulating can help to solve
whatever vehicle you are most comfortable
the problem. For example, an anxious and
withº (Beck, 1991). Formulations, just like
hypochondriacal patient who was worried,
maps, provide an overall view (often in
among other things, about seeing ªfloatersº in
diagrammatic, conventional form) of some-
his visual field, started to respond well to
thing that it is not possible to see directly all at
treatment that was formulated in terms of his
onceÐthe wood as well as the trees. They
underlying sense of vulnerability. The formula-
indicate which are the important features, their
tion reflected the way in which his various
size and shape, and the way in which they relate
concerns made him feel threatened, and think
to each other. Mapping the territory is clearly
that he was at risk for being unable to handle a
the product of accurate assessment (see Section
number of initially rather vaguely specified
6.01.4), and formulating enables therapists to
distressing eventualities. However, although
make and to justify such statements as ªthis lack
his confidence increased, his distress about the
of energy is part of the depression,º or ªin this
floaters did not diminish. If anything it in-
case the anxiety seems to be primary and the
creased, in tune, it must be acknowledged, with
depression secondary.º Similarly, formulations
the therapist's frustration when discussing this
can indicate where information is missing and
issue became his main priority. Focusing the
prompt appropriate questions: where did this
work of one session on the meaning or under-
low self-esteem come from? Why does it become
standing of this problem revealed (for reasons
apparent in the context of close personal
which later became clear) that visual anomalies
relationships but not at work?
for this person felt, in his words, ªlike a
bereavement.º Formulating this aspect of the
6.01.3.2 Prioritizing Issues and Problems problem in terms of loss rather than in terms of
vulnerability changed the focus of treatment,
An overall formulation helps to differentiate which then became more productive. This
what is essential from what is secondary in a example also illustrates how characteristics of
general sense. It also helps in a more particular the process of therapy can contribute to ideas
way to decide which issues or problems should be about the formulation, especially in those cases
prioritized. Someone who believes that they in which change is not proceeding as well as
cannot change is unlikely to remain engaged in might otherwise be expected.
Table 1 Summary of the purposes of formulation.
Clarifying hypotheses and questions

Understanding; providing an overall picture or map
Prioritizing issues and problems
Planning treatment strategies
Selecting specific interventions
Predicting responses to strategies and interventions; predicting difficulties
Determining criteria for successful outcome
Thinking about lack of progress; trouble shooting
Overcoming bias
6.01.3.3 Planning and Selecting Intervention Clearly, this overall strategy reveals assump-
Strategies tions about how the effects of these events can
be understood, about the effects of talking
Once a hypothesis about how the presenting about them, and the interventions usedÐ
problem can be understood has been formu- assumptions which formulations clarify, and
lated, the most important functions of a which are potentially amenable to research, but
formulation are in planning a treatment which will differ according to the therapist's
strategy and selecting appropriate methods of theoretical orientation. A secondary purpose of
intervention. Persons (1989) provides some clarifying the formulation and its function in
lucid examples: someone who avoids exercise selecting strategies and interventions is to
because they are bad at time management, facilitate evaluation of interventions.
scheduling, or self-organization has a different
problem to overcome, and needs to acquire
different skills from the person who avoids 6.01.3.4 Predicting Responses and Difficulties
exercise because they are embarrassed about
their appearance; insomnia that is associated Because a formulation reflects theoretical
with the fear of letting go may require different assumptions, it helps therapists make two kinds
interventions from insomnia that results from of predictions that are essential in therapy: to
overcommitment. predict the effect of the intervention, assuming it
The way in which a problem is formulated is successfully applied, and to predict the
thus determines what should be done about it stumbling blocks and difficulties that will be
(Blackburn & Twaddle, 1996; Butler & Low, encountered during therapy. An anxious person
1994; Eells, 1997). If avoidance maintains the treated during a clinical research trial (Butler,
problem, then facing the fear is likely to reduce Fennell, Robson, & Gelder, 1991) held the belief
it, and in individual cases the formulation helps that ªall my ideas are bound to be wrong.º She
to specify idiosyncratic aspects of the avoid- became more confident as she learned to identify
ance (the spider phobic who will not walk her ideas, to act upon them, and consciously to
under trees; the social phobic who is more evaluate the consequences of doing so. Her
fearful of silence than of conversation). The formulation enabled us to predict first that she
general vicious cycle model is common to would feel especially vulnerable and be likely to
bothÐand indeed, a standardized method of overgeneralize and catastrophize the conse-
treatment of proven effectiveness, exposure in quences when she made mistakes, and second,
vivo, is readily available. The individual that she was likely to find it especially difficult to
formulation is still necessary because it apply the new strategy when relating to her
specifies exactly what steps to encourage the partner, but easier to build up the necessary skills
person to take. (and courage), and to increase her confidence, in
Planning overall strategies is just as impor- the context of other relationships (including
tant a product of formulation as the selection of ours). Treatment in this case was guided by the
specific methods of intervention, but is a more requirements of a treatment manual, and the
complex task, and requires of the therapist more example illustrates the important role played by
than one level of understanding. The way in clinical formulation in the application of
which depression or anxiety is understood may standardized treatments.
suggest, for instance, that it would be helpful to It is probably true to say that interpersonal
increase levels of activity before discussing difficulties are one of the most common sources
thoughts associated with depression; or to build both of patients' problems and of problems
up a repertoire of coping skills before facing encountered during psychological therapy; for
fears. Many such imprecations are based on example, an ability to form superficial relation-
clinical judgment (or clinical intuition) as much ships without being able to sustain deeper
as on theoretical or experimental work, and in friendships, or veering between passivity and
these cases it is especially important that they aggression when interacting closely with others.
should be made clear by means of a formula- Such difficulties also play their part within the
tion. For example, it is often said that when therapeutic relationship, and they are much
working with people who have suffered abusive more easily dealt with if the processes involved
experiences in childhood, one should help them have been understood in terms of the theory
to develop a variety of support systems, ways of being used, and problems predicted in advance.
dealing with intense feelings or suicidal impulses Formulating helps people to recognize such
and of creating around themselves a sense of patterns, to develop hypotheses about their
safety, before exploring memories of early origins, functions and effects, and to think
traumatic experiences, and the meanings of about whether and how to engage in a process of
such events, in depth. change.
Purposes: What a Formulation is for 11
6.01.3.5 Determining Criteria for Successful 6.01.3.6 Thinking About Lack of Progress
Outcome
There are many possible reasons for lack of
Theoretically a formulation provides the progress in therapy, including working without
basis for hypotheses about what needs to making a formulation. The first line of defence
change for someone to feel better, or the goals when this happens must be to formulate or to
of therapy in the broad sense of the term. This is reformulate the problem. The way in which this
obvious when a theoretical model for the is done will have specific implications for the
condition being treated is available, but the next steps in therapy. For example, if the
point applies more generally as well. The problem is a long-standing, chronic one, it may
present version of the cognitive model of social be that much practice is needed and that it is
phobia (Clark & Wells, 1995), for example, unrealistic to expect faster change, in which case
suggests that self-awareness, or self-focused it may be important to think about how to keep
attention, plays a central role in the disorder. In the momentum of change goingÐabout how to
outline, when in a socially frightening situation maintain hope and create the energy for change
a social phobic feels self-conscious, notices when doing so is difficult. If the original
symptoms of anxiety and tries to keep safe. An formulation was inaccurate or incomplete, the
individual formulation based on this model failure to change may suggest that different
would specify the way in which this actually strategies and interventions are needed. When
happens. For example, when speaking to others lack of progress leads to frustration, and the
(e.g., colleagues during a lunch break), Marie reactions of both the patient and the therapist
became aware of the sound of her own voice, felt interfere with subsequent progress, including
anxious, flustered, hot, and shaky, and found it these factors in the reformulation can reveal
hard to listen to what was being said. She ways of overcoming them. Blocks in treatment
thought other people must be able to see how are nearly always informative and formulation
nervous she felt and tried to fade into the skills should be used to identify their specific
background as quickly as possible (keeping nature.
herself safe by avoiding eye contact, saying Often this is complex and involves making
little, speaking in a quiet voice). Both general hypotheses about past events, the exact nature
and specific goals for change can be derived of which can never be known. Possible
from thinking along these lines. In simple terms, formulations in these circumstances, often
if Marie can focus her attention outside herself, derived from a combination of observation
and listen without self-criticism to those around and understanding of the apparent effects of the
her, if she can reverse the safety behaviors (make past on the present, can suggest which avenues
appropriate eye contact, speak more audibly, to explore so as to make further progress. For
move around freely), she will break the cycle example, a patient who provided a cold and
and start to feel less anxious. The general dispassionate account of a childhood in which
criteria for change are reflected in the three she was neglected, often frightened and some-
elements of the model specified here, the self- times threatened with physical abuse, appeared
awareness, safety behaviors, and symptoms of to have developed a variety of ways of
anxiety, and specific ones reflect the individual controlling both the experience and the expres-
ways in which these factors are manifested in the sion of her emotions. Many, but by no means
case of Marie. all, of these ways were dysfunctional. A possible
Of course this might not be the whole story. formulation of this case suggests that improve-
Marie's social anxiety may be based on a belief ment will remain blocked unless or until she
in her own unworthiness relative to others, and becomes able to experience and express the
reflect an unhappy history of family relation- relevant feelings. Doing this is likely in the first
ships. Such formulations again indicate criteria instance, to precipitate periods of distress, and
for changeÐa sense of worthiness or the ability the precise implications for therapy to be
to form more satisfying relationships in the derived from it will depend on both the skill
present. The difficulty here is that more and the emotional sensitivity of the therapist as
abstract and general phenomena are harder well as on a willingness to adapt the formulation
to identify, define with any precision, and according to what happens.
measure than more superficial and specific Drawing these points together, it is clear that
ones. Criteria for change are therefore more formulations cannot be treated as a matter of
easily derived from formulations at lower than last resort, only to be constructed and worked
at higher levels of abstraction, and indeed the on when the going gets difficult, when dealing
more specific the formulation the easier it will with chronic problems, when treatment has
be to be clear about what exactly needs to apparently gone on too long, or when preparing
change. to report to someone else. Formulations do not
provide the answers to questions, but a rich sumptions, attitudes, beliefs, images, etc.);
source of questions and ideas of potential affect, behavior, and physiological sensation;
therapeutic value. They should not become the present context for the ways in which these
the tool for applying a preconceived theoretical things are manifested; and an account of their
plan to someone for whom the plan does not fit, background and associated developmental his-
nor should they focus exclusively on someone's tory. It also draws on information gathered
problems and difficulties. Accurate formulation during the process of referral, such as a summary
takes account of a person's strengths as well as of the problems as understood by the referrer, of
failures, talents and potential, as well as short- the reasons for requesting help and of responses
comings and failures. to treatment received so far, and on the
If formulations can be so useful it is surprising impressions and observations made during the
that so little attention has been devoted to them first encounter with the therapist when the
both within training programs and in the processes of mutual interaction are set in
literature. One reason for this may be that motion.
formulations were supposed to follow logically Therapists use many skills in helping them to
from the processes of assessment and functional understand this material: theoretical know-
analysis, and additional skills were not often ledge; products of academic learning and
specified. A more important one is probably that professional training; and clinical judgment.
formulating is difficult. As already indicated, in The process of encapsulating this understanding
practice it involves exercising clinical judgment in a formulation, which at first takes time and
as well as the ability to relate theory to practice. becomes quicker with practice, is facilitated by
Also, until recently, there was less communica- adopting a questioning stance. The aim would
tion between people with different theoretical be to be able adequately to answer three of the
backgrounds, and fewer challenges to think key questions that patients ask: Why me? Why
about alternative methods of formulating spe- now? What keeps it going? and in doing so it
cific cases. So, the next important question is helps to draw on a further set of questions
ªHow do you construct a formulation?º central to the process of formulation, which
therapists can pose either to themselves or to
their patients: How do you understand that (or
6.01.4 METHODS: HOW TO CONSTRUCT make sense of it)? What do you think is going
A FORMULATION on? How does this all fit together? What might
be the missing links? What does that mean
The main reason for considering the purposes
about you now? Is there a pattern here?
of formulation before thinking about how it
Formulations are useful in helping people to
should be done is that there is no single correct
think again about their difficulties, and see them
methodÐhow you do it is in general determined
in a new (e.g., clearer, more realistic, or more
by understanding the purposes that it serves,
illuminating) light, and the process of assess-
and in particular by the theoretical orientation
ment potentially reveals the patient's present
of the therapist. The end product should enable
point of view. In order to develop an under-
the therapist to relate theory to practice in a way
standing of such personal and unique phenom-
that can direct and inform the process of
ena, it is particularly useful to pay attention to
therapy, and the methods used vary enor-
the ways in which people react to their
mously. For the student this is both confusing
experiences. Their comments provide a rich
and liberating, as it demands creativity and the
source of such informationÐªI have to keep
ability to deal with abstractions as well as the
controlº or ªI need to know I am succeedingº
more mundane skills primarily involved in
are remarks that suggest hypotheses about the
assessment. Assessment is a necessary step in
self and about underlying processes and
the development of a formulation, but it is not a
mechanisms. Ideas expressed about others, such
sufficient condition for it. Unfortunately, it is
as ªshe'll be miserable aloneº may fit with
possible to assess, in the data collection sense,
assumptions that precipitate or maintain pre-
without developing a formulation.
senting problems. General comments of the
kind ªyou have to conform or you can't get onº
6.01.4.1 Sources of Information reveal attitudes that may (or may not) dominate
within the real world in which the person lives.
An account of presenting problems, informed Expectations about the future, including those
by knowledge of psychological processes and about the process and outcome of therapy, are
diagnostic systems, provides a common starting also revealing: ªI won't be able to do what is
point, and assessment covers all of the four needed,º ªThere are some things I would rather
aspects of functioning illustrated in Figure 1 and not talk about,º ªI'm relying on you to make me
their determinants: cognition (thoughts, as- better.º In order to formulate, it is important to
Methods: How to Construct a Formulation 13
understand the personal significance of experi- formative. This may sound unrealistically
ences as well as their phenomenology. These demanding, as if every sentence the therapist
comments illustrate well how the processes of utters should be shaped by the developing
formulation and assessment meet, and indeed formulationÐindeed, it is intended as a rule of
may overlap. Therapists assess to find out about thumb rather than as a categorical imperative.
problems and their context, and they formulate However, it is less unrealistic than it might seem.
differently according to what they think their The initial question in the therapist's mind
findings mean. could be quite a simple one, for example: Is the
Patients' comments may need clarifying withdrawal described by this person associated
during assessment if they are to inform the with feelings of depression and sadness or is it a
process of formulation maximally. Statements kind of avoidance motivated by fear? Will
that are apparently clear to the person expres- attentive listening help this person feel suffi-
sing them may not be clear to the therapist, or ciently comfortable to disclose significant
may reveal ambiguities and contradictions, as material? Are my questions too specific and
when angrily saying ªI'm not capable as a intrusive at this stage? Answers to these
parentº (when sadness sounds more likely and, questions could of course lead to more complex
superficially, more appropriate), or when ones: Is this person's reticence a product of
commenting wryly that ªI felt sorry for myself,º experiences that have destroyed trust? Does it
without elaborating on what that means. One of reflect a preference for an autonomous style of
the most useful sources of information for relating to others? Is it a product of inexperience
formulation comes from the mutual reactions of and lack of practice or opportunity in talking
the patient and therapist to each otherÐ about intimate and personal matters? Is this way
information that is used differently in different of interacting culturally unfamiliar to them?
types of therapy, and which is understood using The second point is that the process of
different theoretical systems, of varying degrees therapy should not be artificially separated into
of sophistication, but which is always relevant. discrete stages of assessment, formulation, and
The processes of assessment and formulation treatment (or intervention). It is not that these
therefore go hand in hand, and inform each processes cannot be distinguished, or that one
other, but they remain different processes. Ideas or other of them may not predominate at a
about how to understand (conceptualize or particular time, but that they cannot in practice
formulate) what is being said, about its personal be wholly separated from each other. Thus, one
meaning and implications for theorized psy- of the hardest tasks therapists have to learn is
chological structures and processes, guide how to bear all three of them in mind at
questions and observations. When formulating onceÐhow to gather information, think about
as well as when assessing, the information it in theoretical/structural terms, and remain
gathered changes and shapes these ideas as aware of the various ways in which they are
hypotheses are formed, revised, and (theoreti- likely to exert an influence, so as to enhance the
cally) refined. So, making a formulation is not a potential for productive change, rather than
one-off activity that defines a fixed state, but the limit or delay it.
reflection of a dynamic process, and the The many sources of information available to
resulting system of understanding develops therapists when starting to develop a formula-
and changes over time. This is why the process tion, assuming an adequate process of assess-
of formulation should start at the same time as ment has been set in motion, are summarized in
the process of assessmentÐjust as the process of Table 2. This list includes both direct and
finding ones way around a new place starts with indirect sources of information, information
the first encounter with itÐand may be on paper from standardized questionnaires, and from
rather than in person. initial interventions such as self-monitoring and
Two points that follow from this line of homework assignments (when these are used).
argument help to determine how a formulation The purpose of this summary, in the context of
is made. First, if therapists are always for- the preceding discussion, is not to overwhelm
mulating as well as assessing, then their therapists with long and exhaustive lists of
questions and statements should be guided by material to be gathered, items to consider,
conceptual hypotheses. They should always be processes to complete, and so on, but to illustrate
able to answer the question ªWhy did you ask that there is an enormously rich source of
that then?º The answer should not just be relevant material potentially available, and the
phrased in terms of curiosity or information process of formulation can draw on any of it,
gathering, but should relate to a hypothesis beginning anywhere. The process of formulation
about how to understand the minutiae of the is essentially one of abstraction and it works by
case. The patient's response to the therapist's relating observable phenomena to hypothetical
comment or question is then maximally in- underlying processes and mechanisms. It is not
necessary to observe everything before making a other patterns, for instance in interpersonal
guess at what lies underneath. An (informed) functioning, sequences of behaviors and their
guess may either indicate the need for more consequences; thoughts, feelings, attitudes, and
assessment or it can short circuit the process. beliefs; dilemmas and traps. In this example
Because formulating is a dynamic process, and (Figure 2), a woman living through a stressful
depends on the ability of the therapist to retain period described feeling tired much of the time
an open mind, the process can productively start and being unable to relax. Asked about what
to serve the functions listed in the previous goes through her mind when trying to switch
section straight away. Therapists can focus their off, she described a stream of worries, most of
minds on the process of formulation by asking which were rather vague and hard to specify in
more formal questions: How can I understand detail. The worry disturbed her sleep pattern,
the information I have been given in terms that which exacerbated the tiredness. A cycle, which
make theoretical sense? What implications does symbolizes how one thing leads to another, can
that understanding have for what to do next? easily be illustrated diagrammatically, and it has
What difficulties will I have, working with this obvious implications. Breaking the links will
person? What difficulties will they have (work- help to solve the problem, and this can be done
ing in this way) with me? What use will this in various ways, such as learning to relax,
person be able to make of treatment? Answers identifying and dealing with the worries, or
help to determine how to intervene and to predict taking hypnotic medication. The assumption
what will or will not happen as a consequence. behind the formulation so far is that the
problem will subside if the process that
maintains it is interrupted, and the intervention
6.01.4.2 Putting the Information Together selected could be determined by the preferences,
understanding, or skill of either of the parties
Given that a formulation provides connecting involved.
links between theory and practice, the precise However, a formulation essentially relates
form that it takes will be partly determined by theory to practice. Applying the cognitive
the theoretical approach of the person making model to this case would suggest that a close
it. Nevertheless, some general points apply, and relationship between thoughts and feelings is
these are illustrated here using the cognitive- likely to be of central importance. There are at
behavioral approach. least three ways in which this initial formula-
First, initial formulations can provide cross- tion, in its hypothetical and simplified form, can
sectional understanding of an aspect of the help the cognitive therapist to focus on factors
presenting problem. The most obvious example that theoretically are likely to be relevant. It
is probably that of a vicious cycle which identifies worry as an important cognitive-
summarizes the way in which a particular, maintaining factor, it reflects an overall under-
readily accessible, symptom pattern is thought standing of the problem, suggesting that the
to be maintained. It is used here to illustrate the symptom pattern is recognizable, understand-
way in which a formulation helps to specify able, and changeableÐattitudes which may
processes, links, and mechanisms. In this case differ strikingly from those the patient starts
the focus is on certain kinds of links. Other withÐand it poses questions about the context
cross-sectional formulations might focus on of the problem. Nothing has been specified
Table 2 The main sources of information for use in formulation.
Examples of direct information

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

unable to relax
Can’t sleep Worries keep

well coming to mind
Figure 2 Example of a simple cross-sectional formulation: basis for a more complex formulation.
about why this is, for this person, a stressful always please others they'll never find out about
period. Theory-driven questions help to develop me,º ªI'll be OK if I stick to doing easy things,º
more hypotheses: What does it mean about her and ªPeople will reject you if you don't toe the
habitual response to stress? How does she line.º In this diagram, three aspects of his
construe her present situation? What does her problem are represented in different ways. First
reaction to it mean to herÐabout herself, about there is a rather shapeless ªthought bubbleº at
other people, and/or about the world in which the top in which hypotheses about underlying
she finds herself? So, the initial formulation cognitive structures, beliefs, attitudes, and rules
triggers further inquiry, and starting from a about himself have been put into words: ªI'm
simple cross-sectional map can lead to more incompetentº; ªI have to do what others askº;
sophisticated levels of understanding, and to ªI'm thick (stupid) . . . º These actual words
more complex formulations, as well as being were his responses to specific (theory-driven)
practically useful. The precise way in which this questions, and they illustrate how the process of
happens will be determined by the theory being formulation interacts with that of assessment,
used. and depends on the ability to abstract and to
Cross-sectional formulations can also pro- generalize. The broken line is labeled a
vide an outline summary of the way in which ªprotective wallº because it represents the idea
complex underlying factors are understood, or that the three statements listedÐstarting points
of the way in which aspects of a problem are for a more detailed formulationÐreflect beha-
linked. Three statements made by an unem- viors that serve a function. Reacting in these
ployed, unconfident young man with a wide ways protects him from having to confront (the
range of social, interpersonal, and affective hypothetical) underlying beliefs and attitudes,
problems were used as the starting point for the and prevents others from discovering them,
initial formulation illustrated in Figure 3: ªIf I both of which would be painful experiences for
him. However, these protective reactions cause mechanisms as well as about the relevance and
problems, not specified here but referred to in relative importance of different facets of a
the box in Figure 3. This formulation con- problem. Longitudinal formulations reflect
tributed to the process of developing a shared assumptions about etiology as well. They are
understanding of some complex problems, and used in most kinds of therapy, and are readily
it was used to explain how change would illustrated in the case of CBT. The basis for
probably involve working at all three levels. It using this theoretical model in clinical practice
also has implications for decisions about has been summarized in the form of a template
general aspects of therapy. For example, it (Table 3) which can be used to illustrate how
suggests that at times this will be a distressing theoretical understanding can be translated into
process that will demand sensitivity and a good practice. This shows that, theoretically, experi-
sense of timing from the therapist. ence, both early in life and subsequently, gives
Cross-sectional formulations potentially re- rise to a set of beliefs and assumptions about the
flect ideas about psychological processes and world, about other people, and about the self.
I’m incompetent
I have to do what others ask
I’m thick
Protective wall:
“If I always please others they’ll never find out”
“I’ll be OK if I stick to doing easy things”
“People will reject you if you don’t toe the line”
Me with my
problems
Figure 3 Example of a cross-sectional formulation.

These beliefs are seen as a product of the ways in belief change that follows. The processes of
which earlier events have been perceived, change may, or may not, be set in motion by
understood, and remembered. They can be work at this level. If not, then another
functional or dysfunctional, actively influential hypothesis might be that one of the many
or latent at any particular time, and relatively processes now available for changing beliefs
easy or hard to identify and to recognize. A should be adopted as well as or instead of. This
critical incident (see also below) is an event that example is not meant to explain how to do CBT,
fits with a beliefÐbeing rejected for someone but to illustrate how the internal map provided
who believes they are not socially acceptable, or by a theoretical understanding relates to a
being let down for someone who believes that specific formulation, and how therapists can use
other people are unreliable or untrustworthy. such maps as guides even when there is
Critical incidents activate the relevant beliefs incomplete evidence for the theories upon
and assumptions, and thus produce negative which they are based. Doing so enables them
automatic thoughts (NATs). Then a variety of to explain what they have been doing, and it
interacting cognitive, affective, behavioral, and enables others to decide whether their actions
physiological reactions follows. At this level the were skilful, appropriate, and so on.
problem is theoretically maintained by cyclical
processes of the kind summarized in the cross-
sectional vicious cycle described above. 6.01.4.3 Key Factors and Basic Elements
Clearly a template such as this can be used to
structure information about a patient, and this This example also illustrates that when
will have implications for what the therapist learning how to construct a formulation, it
does. For instance, if it appears that dysfunc- can be helpful to think in terms of key factors.
tional beliefs play a small part in the presenting Critical incidents provide a good example of
problem, or are well balanced by a set of positive these as they reflect the way in which hypothe-
beliefs, the theory (and the formulation derived tical underlying mechanisms are manifested,
from it) suggest that the work should focus and link these with observations about present
predominantly on the level of maintaining phenomena. Critical incidents are ªcriticalº
factors. Another type of implication might because they provoke a high degree of affect,
reflect the degree of verification available for the often in excess of what might otherwise be
theory. For example, psychologists do not yet expected (an over-reaction, such as becoming
know which are the most effective ways of enraged if kept waiting for 10 minutes); they are
changing beliefs (the cognitive frameworks with easy to notice and remember, and are of special
which people approach the world). One com- significance for the person who experiences
mon strategy is therefore to begin working at the them. Examining them potentially reveals other
level of the NATs and to evaluate the degree of elements of the CBT template: underlying
Table 3 Template for a longitudinal formulation using cognitive-behavior therapy.
Experience (early or otherwise)

;
Beliefs, about the self, the world, and others, which are expressed in
categorical statements: I am . . . ; the world is . . . ; others are . . .
;
Assumptions derived from beliefs, which can be expressed in
conditional statements: If I . . . then . . . ; One should . . . otherwise . . .
;
Critical incidents
;
Activated beliefs and assumptions
;
Negative automatic thoughts (NATs)
; :
Cognitive, behavioral, affective, and physiological reactions
beliefs, preferred coping mechanisms, main- indicates what the problem is, and where to
tenance cycles, and so on. Focusing on critical intervene, but (being atheoretical) cannot
incidents is thus theoretically helpful when indicate how to do so. It cannot therefore
stuck in constructing a cognitive formulation. provide specific implications for treatment, but
This is not to say that all cognitive therapists it does provide a common language, and using
think about them, or base their formulations this it is potentially easier to find out precisely
upon them. An alternative method might how theories differ when put into practice.
involve working from a problem list, weighting
the problems for importance, and going on to
abstract and understand the connecting themes 6.01.4.4 Issue of Completeness
and links in ways that fit with the theory. The
point is that within a particular method of The formulations illustrated so far have been
working there are many ways of constructing a kept simple for the sake of clarity, to emphasize
formulation, but it can be helpful to keep those the point made at the beginning about the
factors in mind which play a central part in the principle of parsimony, and because they
theory, or in revealing the manifestations of demonstrate the point that it is never too soon
important theoretical constructs whether these to start formulating. They are examples of
are core beliefs, core interpersonal schemata, or initial hypotheses. As treatment progresses they
core conflicts. To repeat, there is no single would be likely to become more complex and
correct method. also to take more account of a person's
Use of the word ªcoreº suggests that developmental history and the supposed under-
formulations may be thought to have certain lying mechanisms.
basic elements, and that unless these are This raises an important issue for discussion.
identified the formulation will, in Perry et al.'s Many people assume that formulating is a
words, ªlack an integrative coherence.º When difficult and lengthy process, the aim of which is
writing about psychodynamic formulation and to encompass, systematize, and explain all
about central conflicts, Perry et al. (1987, p. 546) relevant factors about a particular case. This
say ªThe aim is to find a small number of view can lead therapists either to bypass the
pervasive issues that run through the course of process of formulation and start treatment
the patient's illness and can be traced back straight away, or to delay the start of treatment
through his or her personal history, and then to until they have got the picture right. Both of
explain how the patient's attempts to resolve these reactions cause problems: bypassing the
these central conflicts have been both process makes it hard to move beyond the stage
maladaptive . . . and adaptive.º The overall of trial and error; interventions are selected in
intention is clearly closely similar across the absence of a coherent underlying strategy.
different therapeutic orientations, as is the This seems to be successful when the patient
general approach: first, apply a particular, responds well (as many patients do initially), but
theory-driven model; if that does not in practice it leaves both parties feeling confused and
fit the particular case, explore further using unable to understand what has happened when
questions and trial and error in the (scientific) half a dozen sessions later progress is halted and
search for a formulation that fits better. setbacks are encountered. It is rather like trying
This process might be facilitated if there was to stop a car rattling by cleaning and adjusting
agreement over which were the basic elements of those parts of the engine that are most
a formulation and an atheoretical way of linking accessible. Delaying the start of treatment is
them together. One way of doing this has been another false economy, for many reasons: the
developed by Goldfried and his collaborators. initial momentum provided by a fresh start and
This transtheoretical coding system ªwas devel- a new encounter may be lost; the impact of being
oped as a common language for use in listened to, heard, and understood by someone
conducting comparative process research across new may be dissipated; and the goodwill,
orientationsº (Goldfried, 1995, p. 222). It advice, and new ideas derived from interacting
specifies which are the relevant components with a trained therapist may not be harnessed in
of functioning (e.g., self-observation, self-eva- a way that is either helpful or informative (or
luation, intention, emotion, and action) and the both). So, opportunities to test hypotheses may
types of links that can be made between them be lost.
(vicious cycles, patterns, contradictions). These In an ideal world therapists, believing that ªat
can be manifested both in intra- and inter- some level it all makes senseº, would be able to
personal contexts, involving other people or use their formulations to make sense of the
not, over a particular time frame. One advan- material presented in a particular case. But at
tage of this type of formulation, the coding present complete formulations, like complete
system of therapeutic focus (CSTF), is that it theories, are not possible. A person cannot be
summarized in a diagram. But some of their metaphorical formulations are provided in this
problems and patterns of behaving can be section to illustrate how metaphors can en-
understood in theoretical terms and this under- capsulate information about complex processes
standing can be represented in a way that helps that may be hard to specify otherwise. Some
to guide treatment. The complexity and accu- examples are well known and their use has
racy with which this is done varies according to become quite conventional, such as ªa journey
the stage of treatment. of a thousand miles begins with the first step.º
The emphasis on completeness that is often Others are created in a particular therapy
found in discussions about conceptualization context. For example, a manager of an
may be a consequence of the historical associa- engineering company, whose habitual rigidity
tions between medical practice, psychiatry, and was exacerbated by various (personal and
psychology, and the common use of the word industrial) crises, saw himself as ªhanging on
ªtreatmentº to refer to the actions of people for dear life,º and being unable to contemplate
trained in those professions when they are trying change. He was asked to think about how to
to help others. The assumption is that it could be build a building to withstand an earthquake.
dangerous to miss something serious or to apply Thinking about this enabled him to reconcep-
the wrong treatment. So, a complete under- tualize change as a way of developing the
standing is supposedly an essential (or impor- combination of flexibility and rigidity needed to
tant) prerequisite for deciding how to intervene. provide stability in difficult times. Another
The situation is different in psychotherapy (or relatively simple way of representing and
psychological therapy), first because the psy- summarizing a complex process of change
chological influence of one person on another was spontaneously developed by a woman with
cannot be withheld (as can a medical treatment), longstanding problems involving low self-
and then applied when ready, in a self-contained esteem and lack of confidence. She saw herself
package. Various (partially unspecified) factors as ªwobblyº and at risk of falling, as if trying to
are always operating, and in psychotherapy the sit on a two-legged stool. The process of change
ways in which these function will to some degree for her was like ªputting down the third leg.º In
be influenced by the theoretical views and practice this meant many things that contrib-
assumptions of the therapist (as well as by their uted to a sense of stability: developing new skills
personal characteristics). The business of for- and abilities, thinking about herself in new
mulating can direct this process, clarify what is ways, and making more respectful and open
intended, and make the way in which theories relationships with those around her.
are being applied accessible. Formulations do People often use metaphorical language to
not have to be complete to perform this function communicate their experience of distress.
but the method of working with them does have Indeed, it might be more accurate to say that
to be in place. Second, when dealing with it is difficult to describe such experiences
psychological matters, the process of formula- without using metaphorÐpeople explain to
tion is overtly interactive. Patients' comments clinicians how they feel broken, trapped, fenced
and reactions contribute to the process; their in, cast adrift, close to the edge, messed up, out
opinions are relevant, and these may change of reach, cut off, high, low, and so on. Perhaps
over the course of treatment. the most common methaphors describe life as a
journey and ourselves as traveling through
different kinds of emotional weather. Patients'
6.01.4.5 Conceptualizing Processes of Change understanding (or personal formulation) of the
processes involved is also reflected in the words
Therapists seek understanding of the way in used to describe their experiences: ªI've hidden
which change takes place as well as of the way in myself away . . . built a protective wall around
which problems arise and persist, and they may me . . . had to harden my shell . . . can't see my
also formulate this understanding in theoretical way out of the tunnel . . . waited to be rescued.º
terms. Conceptualizing the processes of change It is hardly surprising that the processes
is thus another way of relating theory to involved in therapy are similarly described.
practice, and formulations may be technical, Someone who came to understand the stultify-
phrased in terms that are derived from the ing and self-destructive effects of overt com-
particular theory being used, or metaphorical. pliance with the wishes of those around her,
Technical formulations might explain how despite her own inclinations, and the relation-
changing reinforcement patterns would change ship of this pattern of behavior to the fear and
behaviors, how change in one person will anger for which she was requesting help, said
prompt the system around them to adjust, or that she felt as if she had spent her whole life
how changing patterns of defensiveness might trying to grow flowers in her garden and cutting
change opinions of the self. Examples of off the buds before they could flower. She saw
therapy as a process that would help her to clearer implications than one which is phrased
allow the flowers in her garden to bloom. in more general, abstract, and high-level terms.
Undoubtledly, the process of developing a Presenting the formulation to someone else, or
shared understanding is a complex one, and putting it onto paper, is therefore a useful and
the more abstract the material considered, the revealing exercise.
more difficult this process will be. Although a
metaphor is not a formulation, and it may
reflect only part of what is involved, using one 6.01.5.2 Questions for Research
can help to fulfill some of the purposes of
formulation that were described above, and it It would probably be fair to say that, of the
can do so with a startling degree of economy many questions that could be asked, few have
and emotional sensitivity because it operates at been studied and none have been conclusively
more than one level. answered. Persons, Padesky, and Mooney
These examples have been chosen because (1996) found only moderately good inter-rater
they illustrate a point not so far emphasized reliability of cognitive-behavioral formulations
about formulation, that it is a way of when tapes of initial therapy sessions were rated
summarizing meanings, and of negotiating for by a large group of therapists who had been
shared ways of understanding them and com- trained in CBT, and who varied in their level of
municating about them. When these are com- experience. Surprisingly perhaps, agreement
plex it can be helpful to use metaphor, and of was better with respect to underlying mechan-
course this applies generally, not just when isms than in listing patients' overt problems.
formulating processes of change. A formulation Barber and Crits-Christoph (1993) found, when
provides a source of common language, and reviewing the psychodynamic literature, that
when this is available it can then be used to when clinicians based their formulations on
relate a theoretical framework, at a high level of preset categories, formulations were more
abstraction, to practice, so as to facilitate the reliable, and in addition the predictions of the
process of change. psychotherapy process and outcome were
better. Both these findings fit with the view
that the more clearly specified the activity (as in
6.01.5 ACCURACY: HOW TO TELL IF A CBT and interpersonal psychotherapy, or when
FORMULATION IS RIGHT using clearly defined conceptual categories), the
less room there is for wide-ranging, speculative
Formulations can never be shown to be right
inferences, and the more agreement there is both
as they are hypotheses not statements of facts.
about particular case formulations and about
The evidence may support them or it may not,
their utility.
and they should be judged according to
As discussed above, there has been some
probabilities rather than on an absolute scale
suggestion that making overall decisions about
of rightness. Like other scientific hypotheses,
treatment purely on the basis of a diagnosis may
formulations can only be shown, conclusively,
be at least as useful as basing them on an
to be wrong. Nevertheless, practical guidelines
idiographic formulation. However, a diagnosis
are useful, and a number of attempts have
only enables therapists to make general deci-
recently been made to evaluate their inter-rater
sions about which set of interventions to
reliability and predictive validity (Barber &
employ; for example, to use exposure in vivo
Crits-Christoph, 1993; Horowitz & Eells, 1993;
to help someone with a simple phobia, or those
Persons, Mooney, & Padesky, 1995).
techniques that will assist in resolving a role
dispute in a case of depression treated with
6.01.5.1 Criteria of Accuracy interpersonal psychotherapy. In both cases the
actual steps used will still depend on the way in
A summary of the kinds of practical guide- which the individual case is formulated (Mar-
lines that might provide clinicians with criteria kowitz & Swartz, 1997). The question as to
of accuracy is given in Table 4. Unfortunately, whether treatment that is based on a formula-
the fact that a formulation makes good internal tion is more successful than treatment that is not
sense (provides a plausible narrative for in- is more complex than at first appears. Most
stance) is not a guarantee of its accuracy, which clinicians bring their theoretical knowledge to
should therefore be tested out in practice. It goes bear in the way that they understand, and
without saying perhaps that a formulation communicate understanding about, a case.
which is simple, clear, and easy to understand, They use covert formulations, which may not
and therefore easy to explain, is more readily be made overtly communicable even though
testable than one which is overly complex. One they inform and direct the process of treatment.
which is more specific and low level will have This happens because, once therapists are
Using the Formulation: Practical Issues 21
Table 4 Ten tests of a formulation.
1. Does it make theoretical sense?

2. Does it fit with the evidence? (symptoms, problems, reactions to experiences)
3. Does it account for predisposing, precipitating, and perpetuating factors? (both
overall and with respect to episodes of difficulty)
4. Do others think it fits? (the patient, supervisors, colleagues)
5. Can it be used to make predictions? (about difficulties, aspects of the therapeutic
relationship, etc.)
6. Can you work out how to test these predictions? (to select interventions, to
anticipate responses and reactions to therapy)
7. Does the past history fit (with respect to the person's strengths as well as
weaknesses)
8. Does treatment based on the formulation progress as would be expected,
theoretically?
9. Can it be used to identify future sources of risk or difficulties for this person?
10. Are there important factors that are left unexplained?
thoroughly familiar with the theoretical back- 6.01.6.1 The Value of Organizing and Clarifying
ground to their work, and with the process of
map-making, the activity of formulation cannot Formulating is a way of classifying informa-
be wholly suspended. Once able to recognize tion, putting it into (conceptual) boxes, and
signs of core beliefs or core conflicts, for drawing links between them. It organizes
example, such theoretically meaningful con- information, treatment strategies, and the choice
structs cannot suddenly be rendered invisible of interventions, and it also clarifies under-
again. Formulation skills may still need shar- standing of a case, and therefore the meaning of
pening, and there is certainly a need for more what is observed. This process has some less
and better training (Sperry, Gudeman, Black- obvious advantages as well as the obvious ones.
well, & Faulkner, 1992), especially now that In particular, it helps therapists to see problems
clinicians appear increasingly likely to incorpo- and difficulties as understandable, and this
rate ideas from theoretical orientations other influences their attitudes and expectations. For
than their main one into their work (Messer, example, hostile or passive±aggressive behaviors
1996b). The effects of working with (or without) frequently create frustrations and difficulties
a formulation will remain hard to evaluate. The for therapists, especially when they persist
more important question, in practical terms, is despite all their best efforts. Organizing and
whether or not a particular way of seeing things formulating the information helps therapists to
is put to good use, successfully to do the things see these as characteristic and predictable
that a formulation is for. The struggle is to find a difficulties for which they can plan appropriate
way of seeing things that helps. Although the strategies.
assumption that ªat some level it all makes
senseº still underpins much clinical work, it is
not necessary to believe that there is such a thing 6.01.6.2 Developing an Internal Supervisor
as a ªcorrectº formulation. As Messer (1996a,
p. 136) says, ªAn alternative outlook is that The process of formulation provides thera-
there is no one version of truth possible because pists with an opportunity to achieve on their
we largely construct our realities, which inev- own many things that otherwise they would
itably leads to multiple perspectives on that achieve through supervision. It prompts them to
reality. Wearing different glasses provides reflect about their work with individual cases,
different views of the world.º and to rethink when progress seems blocked. It
helps them to become aware of their own
assumptions and beliefs, and to look out for
6.01.6 USING THE FORMULATION: ways in which these may cause problems, such
PRACTICAL ISSUES as making it hard for them to notice, under-
stand, or work with particular issues. It helps
A formulation does not have to be correct, them to work well with unusual cases or with
but it does have to be useful. The purposes of types of problems that they have not previously
formulation are discussed in Section 6.01.3. encountered. In doing so it helps to build
Here, three practical factors that influence confidence. Formulation is no substitute for
whether a particular formulation succeeds in supervision but, used well, it complements and
fulfilling its purposes are mentioned briefly. extends itÐprovided that the formulation does
not become a fixed way of seeing things that simple and jargon free. It may help to give a
obscures the significance of information that small amount of information at a time and to be
does not fit. ready to repeat explanations, or introduce
technical terms, as necessary. Therapists often
underestimate how much patients can them-
6.01.6.3 Communicating a Formulation selves contribute to the process of formulation,
for instance, by elaborating details, filling in
Some obvious principles can be derived from missing links, or providing contradictory in-
the preceding arguments: the simpler the formation that shows how the formulation can
formulation, the easier it will be to commu- usefully be adjusted.
nicate; it should be presented as a hypothesis, Formulation thus goes hand-in-hand with
not as fact; and initial guesses are worth reformulation, and it is this, as Rosenbaum
checking out as they can indicate whether a (1996) points out, that stops it becoming a way
particular way of seeing things is likely to be of ªfitting something to a known formula.º
productive.
To some degree a formulation is a matter of
judgment. It is based on clinical judgment as 6.01.7 CONCLUDING DISCUSSION
well as on knowledge and facts. As judgments
about people are bound to reflect some of the Formulations reflect the way in which
attitudes and assumptions of the person who therapists make sense of someone else's pre-
makes them, the question arises as to what dicament. They reflect the assumptions brought
should be done with those judgments. Who to bear when thinking about it, the theories
should be told about them? Are there people learned, and the meaning made of it. However,
who should not be told, or circumstances in making sense is not the only thing that they do.
which they should not be disclosed? All therapists are aware that sometimes (albeit
Answers to these questions are partly deter- rarely) providing a formulation can be sufficient
mined by practitioners' ethical guidelines and to bring about change. Such cases show that
procedures for professional accountability. formulations do more than supply
They also depend partly on the theoretical understandingÐthey enable someone to see
orientation of the therapist. In cognitive things differently, to reformulate, or to find a
analytic therapy, interpersonal psychotherapy, new meaning. A business executive whose whole
CBT, and in some forms of short-term career was threatened by an episode of severe
psychodynamic psychotherapy, therapists stress and anxiety was suddenly able to see
make their formulations explicit, and have himself as engaged in a genuine struggle. It was
therefore considered carefully how and when then legitimate, in his view, to experience
this should be done (Beck, 1995; Beck, Free- reactions indicative of both fight and flight.
man, & associates, 1990; Butler & Booth, 1991; His symptoms became acceptable, diminished
Markowitz & Swartz, 1997; Ryle, 1995). The immediately, and he remained well over the
method used is immensely variable, using following six months. Of course this could be
imagery, metaphor, diagram, or verbal expla- understood in many ways: as a healthy
nation, presented in person or in a letter. There consequence of a reformulation, as a miracle
is room here for creative thinking, and sensitive cure, or as a flight into health. So therapists are
adaptation of communication skills, though it also in a predicament. Most of the time only
may help to specify some general principles. some of the facts are available to them, whether
Being on the receiving end of a formulation these are about someone's past life, their
can feel like being weighed up, evaluated, or internal experience or their present relation-
judgedÐlike being ªseen throughº or ships, and the facts that are available are
ªrumbledº rather than understood. This is less consistent with a wide range of plausible
likely if the formulation is presented questio- interpretations. Different mechanisms can be
ningly and collaboratively, at a time when inferred from the same event, as in the example
therapists are clear that patients are able above, or from the same overt problemsÐthe
honestly to give feedback, and while thinking bather's hand movements could signify waving
about how to facilitate the process of feeding or drowning. Equally, the same mechanisms
back reactions in a way that is not just could be inferred from different problemsÐa
superficial or polite. It is important to focus fear of abandonment could underlie both
on strengths as well as weaknesses, and to draw hostile and dependent behavior. The skills of
out implications for change, otherwise patients functional analysis may help to advance the
with chronic problems may conclude that ªthis process of formulation here. To end where we
is the way that they are,º and become hopeless began, Frank (1986, p. 343) said that ªthe best
about change. The language used should be hope of bringing conceptual order into the field
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6.02
Behavioral Approaches
JUÈRGEN MARGRAF
Technische UniversitaÈt Dresden, Germany
6.02.1.1 One Behavior Therapy or Many Behavior Therapies? 26
6.02.2 WHAT IS MODERN BEHAVIOR THERAPY? 27
6.02.2.1 Definition 27
6.02.2.2 Basic Principles 27
6.02.2.2.1 Principle 1: behavior therapy is based upon empirical psychology 27
6.02.2.2.2 Principle 2: behavior is problem-oriented 27
6.02.2.2.3 Principle 3: behavior therapy addresses predisposing, triggering, and maintaining problem conditions 28
6.02.2.2.4 Principle 4: behavior therapy is goal-oriented 28
6.02.2.2.5 Principle 5: behavior therapy is action-oriented 28
6.02.2.2.6 Principle 6: behavior therapy is not limited to the therapeutic setting 28
6.02.2.2.7 Principle 7: behavior therapy is transparent 28
6.02.2.2.8 Principle 8: behavior therapy helps the patients to help themselves 28
6.02.2.2.9 Principle 9: behavior therapy strives for continuous development 28
6.02.2.3 Hollywood or Realistic Expectations: Treatment Goals in Behavior Therapy 28
6.02.2.4 Underlying Methodology 29
6.02.2.4.1 Different types of behaviorism 29
6.02.2.4.2 Guideline 1: the search for lawfulness 29
6.02.2.4.3 Guideline 2: observability 29
6.02.2.4.4 Guideline 3: operationalization 29
6.02.2.4.5 Guideline 4: empirical testability 30
6.02.2.4.6 Guideline 5: experimentation 30
6.02.2.5 The Etiological Approach of Behavior Therapy 30
6.02.2.6 Typical Therapeutic Methods 30
6.02.2.7 Indications 31
6.02.3 HISTORICAL DEVELOPMENT OF BEHAVIOR THERAPY 32
6.02.3.1 Situation at Onset and Precursors 32
6.02.3.2 The ªFounding Periodº 33
6.02.3.3 The Influence of Operant Approaches 35
6.02.3.4 Consolidation and Broadening of Scope 35
6.02.3.5 Integration of Behavioral and Cognitive Approaches 37
6.02.3.6 Continuous Development and the Future 38
6.02.4 EMPIRICAL STATUS OF BEHAVIOR THERAPY 39
6.02.4.1 Problems in Empirically Approaching Efficacy 39
6.02.4.2 Results of Outcome Research 40
6.02.4.3 Consequences of Research Findings 43
6.02.5 PROBLEMS AND CRITICISMS OF BEHAVIOR THERAPY 45
6.02.5.1 Misunderstandings About Behavior Therapy 45
6.02.5.2 Scientifically Well Established, Practically Neglected? 46
6.02.5.3 Current Criticisms of Behavior Therapy 46
6.02.6 CONCLUSIONS 47
25
26 Behavioral Approaches
6.02.1 INTRODUCTION of threat in the face of superior proofs of

efficacy, in hostility toward rational science, etc.
More than most other psychotherapeutic But regardless of their origins, the misunder-
approaches, behavior therapy has been the standings clearly show how important an
subject of misunderstandings. While the self- explicit discussion of the nature of behavior
image of behavior therapists and research therapy is.
results consistently yield the positive image of In the ªfounding phaseº there was a relative
a pragmatic, problem-solving, empathic, and consensus on the definition of the term
frequently successful approach, the outside ªbehavior therapy.º It was generally agreed
perception is often quite negative. The scienti- that this was the clinical application of the
fically oriented language of behavioral publica- learning principles that had been established by
tions seems to have led some observers to the psychological research (cf. Eysenck, 1959).
conclusion that behavior therapy is a highly However, behavior therapy was even in its
technical endeavor that neglects human rela- beginnings a heterogeneous movement of con-
tionship factors. Indeed, surveys of the accep- siderable broadness. Feedback from growing
tance of behavior therapy (EschenroÈder, 1994; clinical practice and vivid research quickly
Heekerenz, 1991; Lutz, Bezold, Bloem, Die- softened the classical learning theory under-
trich, & Wittmann, 1992; Woolfolk, Woolfolk, standing of behavior therapy. Together with the
& Wilson, 1977) frequently show negative progress in the underlying psychological
judgments which often are more pronounced science, its claim to be theoretically founded
in persons that have little information on the and empirically tested generated an ongoing
approach. A remarkable example on attitudes discussion. It is therefore hardly surprising that
toward behavioral approaches is given below. a large number of definitions has been proposed.
ªA rose by any other name . . . : Labeling bias
and attitudes toward behavior modificationº
Using this title, Woolfolk et al. (1977) published 6.02.1.1 One Behavior Therapy or Many
two studies, in which beginning and advanced Behavior Therapies?
students in educational sciences had been shown
a film excerpt of a teacher who applied Definitions of behavior therapy typically
reinforcement methods. Half of the subjects have varied with respect to the broadness of
had been told that the film would show the theoretical orientation and underlying metho-
application of ªhumanistic methods.º For the dology. Wolpe (1976) saw behavior therapy
other half, the method was labeled ªbehavior solely as methods that have been derived from
modification.º This simple labeling massively experimentally established principles and para-
influenced the ratings of the teacher and the digms of learning. Similarly, Eysenck (1959)
session. With the ªhumanisticº label, subjects in understood behavior therapy as an attempt to
both studies rated the teacher significantly more change human behaviors and emotions based
positive, competent, flexible, and personally upon the laws of modern learning theory.
attractive. Moreover, they expected clearly According to Agras, Kazdin, and Wilson
better academic results and emotional growth (1979), behavior therapy included already in
from the ªhumanisticº method. The authors the 1970s behavioral and cognitive approaches.
attribute their results to the negative effects of a Even broader, Hollandsworth (1986) saw
frequently technical and mechanistic presenta- behavior therapy generally as the application
tion of behavioral methods. of scientific methods to clinical problems. In the
In addition to external misunderstandings, same vein, Yates' (1970) influential definition
there are also ªself-misunderstandingsº and emphasized that behavior therapy utilizes all the
discrepancies that result from the broad and scientific knowledge accumulated in psychology
frequently stormy development of the beha- and its neighboring disciplines. Among other
vioral approach. Today, there are many important definitions were those by the Asso-
different types and opinions about behavior ciation for the Advancement of Behavior
therapy. For example, the classical approach of Therapy (see Franks & Wilson, 1975) and by
Joseph Wolpe is as different from modern Rachman (1988).
cognitive-behavior therapy as is traditional The considerable variability of these defini-
progressive muscle relaxation from OÈst's ap- tions makes it even more important to ask what
plied relaxation or the early operant treatment constitutes modern behavior therapy. An
of depression from Beck's cognitive-behavioral ªeternalº answer to this question is not possible.
approach. The reasons for the misunderstand- The mere attempt to answer this question ªonce
ings on behavior therapy have been sought in and for allº would counterproductively insti-
the polarizing form of its early self-presentation, tutionalize the status quo and impair future
in a lack of information of the public, in feelings developments. The continuous evolution of
What is Modern Behavior Therapy? 27
behavior therapy implies that the question about orientation rather than as a single therapy
its nature has to be discussed at more or less school or group of treatment methods (Mar-
regular intervals. The next section is therefore graf, 1996; Margraf & Lieb, 1994). Modern
devoted to a characterization of modern beha- behavior therapy can then be defined as follows:
vior therapy at the end of its first half century of Behavior therapy is a broad psychotherapeutic
existence. This is followed by a brief sketch of its orientation that is based upon empirical psy-
historical development in order to better under- chology. It includes disorder-specific and gen-
stand its present position. Section 6.02.4 is eral treatment methods that aim at a systematic
devoted to the important question of the improvement of target problems on the basis of
empirical status of behavior therapy and the as much as possible tested knowledge of dis-
practical consequences that this should imply. orders and psychological principles of change.
The chapter ends with a discussion of some of the Interventions have concrete and operationa-
problems and criticisms of behavior therapy in lized goals on the different levels of behavior
today's practice and research. and experience. They are derived from the
diagnosis of disorders and individual problem
analysis and target the predisposing, triggering
6.02.2 WHAT IS MODERN BEHAVIOR and maintaining conditions of the problem.
THERAPY? Behavior therapy is continuously evolving and
explicitly asserts to test its statements empiri-
A mere definition is not sufficient to
cally. The levels of behavior and experience can
adequately describe the nature of behavior
be conceptualized in different ways. In behavior
therapy (Margraf, 1996; Margraf & Lieb, 1994).
therapy, they are typically defined according to
Any meaningful characterization that is open to
Lang's three-systems model (1971). This in-
the future needs to discuss the basic principles,
cludes a behavioral, a subjective, and a physio-
methodological position, and etiological ap-
logical level of response. Although this model
proach that underly the behavioral approach.
can be criticized in some respects (e.g., Fahren-
Moreover, the characterization could easily
berg, 1987), a multimodal approach has become
become a listing of abstract statements if it does
the standard in most of behavior therapy
not include typical treatment methods and their
research (SeidenstuÈcker & Baumann, 1987).
indications.
6.02.2.2 Basic Principles

6.02.2.1 Definition
More important than the abstract definition
Behavior therapy is a genuine psychological is a concrete description of the basic principles
treatment approach that includes a large variety that underly all of behavior therapy. These can
of specific techniques and interventions. In be conceptualized as follows (Margraf, 1996).
clinical applications, these different methods are
utilized either alone or in combination depend-
ing on the nature of the problem to be treated. 6.02.2.2.1 Principle 1: behavior therapy is based
Behavior therapy can therefore not be under- upon empirical psychology
stood as a single, circumscribed treatment Empirical psychology is the scientific foun-
method that relies on one single theoretical dation of the behavioral approach. Behavior
model. On the contrary, its theoretical back- therapy therefore endeavors to operationalize
ground is composed of a multitude of general its theoretical concepts and therapeutic meth-
and disorder-specific etiological theories and ods and to test them empirically. Testing should
psychological models of change. The common be comprehensive using objective, reliable, and
link is the orientation toward empirical psy- valid measurements. In addition to psycholo-
chology. A future-oriented characterization gical knowledge on change principles and
cannot limit itself to a list of present methods. methods, the findings of nonpsychological
The definition of behavior therapy therefore has neighbor disciplines such as biology or medicine
to fulfill the following requirements: are taken into account.
(i) the theoretical and methodological
breadth of the behavioral approach needs to
6.02.2.2.2 Principle 2: behavior is problem-
be included;
oriented
(ii) in spite of broad borders the specific
aspects of behavior therapy have to be named Treatment as a rule aims at present problems.
explicitely; and Therapeutic proceedings are as much as possible
(iii) openess for future developments. tailored to the respective disorders and indivi-
This has led me to the proposal to consider dual patients. Thus, different disorders are
the behavioral approach as a broad basic typically treated in individualized form with
different methods that are based upon empirical They do not, however, ensure transfer into the
knowledge of the disorder. Beyond the solution patient's individual environment. For this, the
of the actual problem treatment typically strives patient has to practice newly acquired strategies
for a general increase in problem-solving between sessions. Although behavior therapists
capacities. This can be achieved indirectly by frequently accompany their patients for ex-
making the therapeutic interventions transpar- ercises outside of their office, the ultimate goal is
ent or by promoting new experiences and always to master problems without therapeutic
directly by problem-solving trainings. assistance.
6.02.2.2.3 Principle 3: behavior therapy 6.02.2.2.7 Principle 7: behavior therapy is

addresses predisposing, triggering, transparent
and maintaining problem conditions
Behavior therapy wants its patients to be
Behavior therapy distinguishes between pre- informed and active. A plausible model of the
disposing, triggering, and maintaining factors. disorder, an explicit treatment rationale, and
Interventions target those conditions whose the intelligible explanation of all aspects of the
alterations are regarded as necessary for a therapeutic interventions are parts of behavior
durable solution of the problem. Often these therapy that fulfill the legitimate need of the
are the maintaining conditions, because they are patients for an understanding of their condi-
especially important for future well-being. With tion. They elevate treatment acceptance and
respect to predisposing and triggering condi- help to prevent relapse. Transparence thus
tions, most often their present effects are at the increases compliance, comprehension of the
center of attention, because these types of treatment process, and indirectly problem-
problem conditions typically cannot be changed solving capacity. In this way, the acquired skills
post hoc. are better available for application to future
problems without requiring renewed therapeu-
tic assistance.
6.02.2.2.4 Principle 4: behavior therapy is goal-
oriented
6.02.2.2.8 Principle 8: behavior therapy helps
Identification of the problem and the joint the patients to help themselves
definition of treatment goals are integrative
parts of behavior therapy. The problem is the Beyond the increase in general problem-
target of the treatment, its solution means that solving capacity and the transparent derivation
the goal of treatment is attained and the inter- of therapeutic actions from an explanatory
vention can be terminated. Ideally, the explicit model of the disorder, the treatment aims at
agreement on treatment goals should prevent the giving the patient skills for the independent
pursuit of different goals by therapist and patient analysis and mastery of future problems.
or the subsistence of unrealistic expectations. Behavior therapy thus increases the patient's
self-help potential and prevents relapses and the
development of new problems.
6.02.2.2.5 Principle 5: behavior therapy is
action-oriented
6.02.2.2.9 Principle 9: behavior therapy strives
The success of most behavioral treatments for continuous development
presupposes an active participation by the
patient. Mere insight is not a sufficient condition Behavior therapy's orientation on empirical
for the alteration of fixed problems. Behavior psychology leads to a permanent process of
therapy therefore does not limit itself to the evaluation and further differentiation of its
discussion and reflexion of problems, but theoretical concepts and practical procedures.
motivates the patient to actively try new Behavior therapy therefore continuously
behaviors, experiences, and problem-solving evolves.
strategies.
6.02.2.3 Hollywood or Realistic Expectations:
6.02.2.2.6 Principle 6: behavior therapy is not Treatment Goals in Behavior Therapy
limited to the therapeutic setting
What claims should or may psychotherapy
Behavior therapy strives for a generalization make? Some patients and therapists pursue a
of therapeutic effects on everyday life. The ªhollywood perspective,º in which the end of
therapeutic setting and a good therapeutic treatment should be like the happy end of a
relationship offer the framework for learning movie. After successful cure the patient dis-
and testing new behaviors and experiences. appears from the therapist's office into his life
like the victorious cowboy from the movie object of psychological science is exclusively
screen. Although it has become an acknowl- seen in observable (overt) behavior (prominent
edged triviality that for instance love stories end advocate: Watson).
regularly when the relationships and thus new (ii) Radical behaviorism (also called analyti-
challenges begin, the image of permanent cal behaviorism) is a version of radical materi-
happiness shows an astonishing persistence in alism which asserts that the world consists only
the ªtherapy market.º Yet, far-reaching explicit of one matter. Mental phenomena are regarded
or implicit promises of entire restructuring of as mere linguistic illusions that can therefore
personalities, complete freedom from problems, not be the object of scientific psychology
ªimplodingº symptoms, everlasting happiness, (prominent advocate: Skinner).
and perfectly painless mastery of life are not (iii) Opposed to these two types is methodo-
only unrealistic but also harmful. Disappointed logical behaviorism that defines itself not
hopes are especially embittering. Compared to through statements about the existence of
the hollywood standard, one's own achieve- mental phenomena but through methodologi-
ments and experiences may look like failures. cal guidelines that distinguish scientific from
They pursuit of chimeras wastes energy and nonscientific procedures. Even though many
diverts from realistic coping. The more one representatives do not use the term, methodo-
believes in ªhealing promises,º the more logical behaviorism represents the majority in
dependent one gets. Psychotherapy cannot today's empirical psychology, including, for
mean lifelong guidance. Realistic treatment instance, cognitive psychology.
goals therefore have to be coping and help to The basic guidelines of methodological be-
self-help. Even in complex problem constella- haviorism as it is applied today in clinical
tions, therapy can at best attempt to teach new psychology and psychotherapy can be summar-
ways of coping and to identify cardinal points ized as follows (Margraf, 1996; Reinecker, 1994;
that can be used to break old habits. Psy- Westmeyer, 1984).
chotherapy can teach swimming, but the
swimming has to be done by oneself.
6.02.2.4.2 Guideline 1: the search for lawfulness
6.02.2.4 Underlying Methodology The goal of scientific work is to find lawful
relationships that permit description and ex-
Behavior therapy sees itself as an applied planation of the subject of investigation.
science whose understanding of science is ªLawsº do not have to be deterministic,
strongly influenced by methodological ques- probabilistic statements are also recognized.
tions. Being that part of logics that deals with As a rule, different classes of causes are
the logics of research and methods in general, distinguished, although functional relationships
methodology is a central constituent of the traditionally have attracted most attention (see
theory of science. It makes statements about Section 6.02.2.5).
questions such as ªwhat is a hypothesisº or
ªwhat is the goal of scientific research.º The
methodology of behavior therapy is typically 6.02.2.4.3 Guideline 2: observability
called ªmethodological behaviorism.º This may
not be confounded with other types of beha- Only observable events or phenomena that
viorism. are regularly related to observable signs can be
subject of scientific analyses. This does not
imply the restriction to observable motor
6.02.2.4.1 Different types of behaviorism behavior as the exclusive subject of psychology.
Today behavior and experience are the widely
The term behaviorism was from its early recognized subjects of the discipline. Interest-
beginnings part of the struggle of paradigms in ingly, even Skinner did not refuse introspection
psychology. Coined by Watson in order to push as a method if it fulfilled the above requirement.
his view of scientific psychology, the term was
later used primarily by the opponents of
Watson, Skinner, and their followers. The
6.02.2.4.4 Guideline 3: operationalization
intense debate frequently overlooked that there
is not a single type of behaviorism; instead there Assessment of the subject of research has to
are several competing positions. The most be guided by explicit measurement instructions.
common classification differentiates three types Theoretical constructs have to be operationa-
of behaviorism. lized, that is, it must be stated in what way they
(i) Methaphysical behaviorism denies the ex- are represented in variables that can be assessed
istence of consciousness or mental events. The empirically.
6.02.2.4.5 Guideline 4: empirical testability behavioral or psychological syndromes or

patterns that are accompanied by distress,
Hypotheses principally have to be accessible
disability, or reduced functioning on the
to empirical testing, and they must be sensitive
behavioral, subjective, or social level.
to experience. Immunizing strategies that
It is important to distinguish between
attempt to make theoretical statements irrefu-
different classes of ªcausalº factors and to
table are unacceptable because they prevent
investigate their relevance to therapeutic
possible progress in scientific knowledge. Test-
change. The basic approach of behavior therapy
ing of hypotheses can operate through con-
differentiates between three major classes of
firmation or refutation. Under the influence of
etiological factors:
Popper the possibility to falsify general hypoth-
(i) Predisposing factors: These are also called
eses (ªfor all X is true . . . ,º e.g. ªall mental
vulnerability factors or diatheses. Pre-existing
disorders derive from learningº) has gained
genetic, somatic, psychological, or social char-
great importance. Also relevant is the verifica-
acteristics make the appearance of a disorder or
tion of hypotheses of existence (ªThere are some
problem possible or more probable.
Y, for whom is true . . . ,º e.g., ªsome phobias
(ii) Triggering factors: Psychological, so-
are acquired by classical conditioningº).
matic, or social conditions (e.g., experiences,
burdens, demands, events, ªstressº) elicit the
6.02.2.4.6 Guideline 5: experimentation first occurrence of a disorder or problem
under the possible influence of an individual
The best method to test statements is offered vulnerability.
by controlled experiments (which do not (iii) Maintaining factors: False responses (by
necessarily have to be conducted in the the subject or its environment) or lasting
laboratory). For ethical and pragmatic reasons, demands prevent the quick reduction of the
the experimental method has clear limits in complaints and make the problem chronic.
clinical research. Often important variables This ªthree-factor modelº (Margraf, 1996) is
cannot be varied arbitrarily as would be implied not meant to be an all-inclusive explanation of
in a true experiment. Thus, it is ethically mental disorders. Instead, it is seen as a heuristic
unacceptable to induce mental disorders for to help etiological research, the judgment of
experimental reasons. At the most, weak possible starting points for therapeutic change,
experimental analogues for pathological states and the formulation of individual models of
may be induced transitorily (e.g., hallucina- pathogenesis.
tions, sensorical deprivation, anxiety states, The three classes of causal factors can
false feedback of performance). However, the coincide or differ completely, they can be more
question for the ethically acceptable limit has to or less accessible to change, etc. For instance,
be answered for each individual case. The predispositions frequently cannot be changed or
opposite approach to reduce pathological states problem-evoking traumata typically cannot be
or to treat mental disorders also bears ethical undone. The modification of maintaining
problems when conducted in an experimental factors in contrast is often the central mechan-
frame. For instance, randomization of patients ism of change for future well-being. Behavior
to treatments presupposes informed consent. therapy therefore addresses exactly this point
Therefore, research often has to rely on quasi- (e.g., reduction of avoidance behavior in
experimental designs. phobias, training of social skills in schizophre-
nic or depressed patients).
6.02.2.5 The Etiological Approach of Behavior
Therapy
6.02.2.6 Typical Therapeutic Methods
The time of the ªgreatº monistic theories to
explain all mental disorders by one cause or One reason to conceptualize behavior ther-
constellation of causes is over. It has become apy as a basic therapeutic orientation rather
obvious that such complex phenomena cannot than as a single therapeutic school is the large
be explained by simplistic or reductionistic number of often remarkably different methods
ªsolutions.º Today, slogans such as ªbiopsy- that characterize the behavioral approach.
chosocial approachº or ªvulnerability±stress Three classes of methods have to be distin-
modelº dominate the debate. These, however, guished.
can be criticized for being overly unspecific or (i) Basic skills that apply to the therapeutic
lacking concrete content. The behavioral ap- dialogue, the therapeutic relationship or treat-
proach attempts to identify specific causal ment motivation. Although behavior therapists
constellations for individual disorders. Mental in clinical practice typically display high levels
disorders are regarded as clinically significant of relationship skills, they neglected to present
these basic aspects in their early writings. This whether and what kind of psychotherapy is
may have contributed to the overly technical sought. Moreover, even in the case of psy-
image of behavior therapy. Today it is clear that chotherapists these decions are often made in
a good therapeutic relationship is typically a implicit or irrational ways. For example, one
necessary although not sufficient condition for does what one has learned or what fits into one's
therapeutic success. therapeutic ideology. Empirically-based deci-
(ii) General therapeutic methods that do sions are the exception rather than the rule in
address specific disorders. These are methods much of psychotherapy.
that every behavior therapist has to know and This situation is partly due the research
that need to be incorporated flexibly into problems that make a fully satifactory scientific
individual treatment plans. A list of these solution of the question of differential indica-
methods is given in Table 1 (left column). tion impossible. The most popular version of
Several of these methods have been the back- this question was formulated by Paul (1966,
bone of behavior therapy in its early beginnings 1967) as early as 1966: ªwhich is the most
(e.g., systematic desensitization, self-assertive- effectice treatment for this individual with this
ness training, relaxation training). specific problem, by whom and under which
(iii) Disorder-specific treatment programs circumstances?º A complete answer to this
that are tailored as much as possible to the question would involve large experiments with
specific characteristics of the different disor- factorial designs that combine all factors.
ders. Such programs came later in the develop- Considering the number of combinations, this
ment of behavior therapy. Today, they have is illusory. On the other hand, indication
been developed and tested for most important decisions cannot be avoided in clinical practice.
mental disorders. Ideally, they rely upon psy- Behavior therapy therefore pragmatically con-
chological knowledge of the disorders and siders soluble partial questions. First, it is asked
general change principles. Most widely disse- whether psychotherapy is at all indicated, then
minated are programs for various anxiety what type of treatment should be applied, and
disorders, depression, schizophrenia relapse how it should be adapted to the individual case.
prevention, eating disorders, sexual dysfunc- For practical reasons, clinicians need to con-
tions or marital problems in adults, or enuresis, sider not only specific scientific knowledge but
hyperactivity, and aggressiveness in children. A also sometimes untested assumptions, indivi-
list of exemplary programs is also given in dual practical experience, expert or colleague
Table 1 (right column). opinions, and everyday practical knowledge.
Most of the general and disorder-specific In this context, a very important achievement
methods are supported by detailed treatment of behavior therapy is the development of
manuals and a sufficient body of empirical disorder-specific treatment programs (Task
research on efficacy. The mechanisms of change Force, 1995). In its beginnings, behavior
are often less clear. This question forms an therapy meant to a large degree the application
important focus of process research in behavior of general psychological (learning) principles to
therapy. the individual case. Therapeutic procedures
were therefore typically described in the rather
abstract terms of general principles. Over the
6.02.2.7 Indications course of time, procedures were described in
more concrete details. This led to the develop-
The last important aspect that is needed for a ment of treatment manuals which were written
sufficient characterization of behavior therapy for groups of patients rather than for individual
are the indications or prescriptions for its cases. After its publication in 1980, the
application. Decisions about indication are Diagnostic and statistical manual of mental
made every day and in every type of therapeutic disorders (3rd ed., DSM-III) and its succesors
activity. This begins with the question whether rapidly became the the basis for grouping
treatment is at all indicated, continues with the patients. Standard programs for diagnostic
choice between different treatment methods and groups often proved very efficacious in empiri-
their adaptation to the individual, and stops cal testing. Thus, modern behavior therapy has
with the decision about termination. Indication two bases for its decisions: the general char-
decisions thus deal with the optimal fit between acteristics of the disorder and the individual
patients and treatments (and other conditions characteristics of the patient.
such as therapists, settings, etc.). Unfortunately, The pragmatic approach of behavior therapy
only a small proportion of these decisions are to the difficult issue of differential indication
made by psychoherapists. Typically, it is the can thus be summarized as follows: for specific
patient, his relatives, his physician, his health disorders or problem constellations those
assurance, or other lay institutions that decide methods should be preferred whose efficacy
Table 1 Overview of typical cognitive-behavioral treatment methods.
General methods Disorder-specific programs
Exposure-based methods Agoraphobia

Systematic desensitization Social phobia
Flooding Specific phobia
Response prevention Panic disorder
Operant methods Generalized anxiety disorder
Positive reinforcement Obsessive-compulsive disorder
Extinction Post-traumatic stress disorder
Response cost Depression
Time out Anorexia nervosa
Token economies Bulimia nervosa
Cognitive methods Obesity
Self-instruction training Hypochondriasis and health anxiety
Problem-solving training Somatization disorder
Modification of dysfunctional cognitions Somatoform pain disorder and chronic pain syndromes
Reattribution Schizophrenia
Analysis of erroneous logics Sexual dysfunctions
Decatastrophizing Marital problems
Modeling Hyperactivity and attention deficit disorder
Social skills training Aggressiveness
Self-control methods Autism
Self-observation
Self-reinforcement
Stimulus control
Multimodal therapy or
broad-spectrum therapy
has been validated empirically. Based on a evolved from the application of the principles
detailed problem analysis and the course of of experimental psychology to clinical problems
treatment, standard interventions should be (Kazdin, 1978; Schorr, 1984, 1995). Its growth
adapted to the individual case. This should take was closely related the development of clinical
individual strengths and weaknesses, person- psychology as an applied science. Although
ality, life situation, and setting variables as well there had been sporadic early clinical applica-
as possible interactions of these factors into tions of psychology (e.g., the case of ªlittle Peterº
account. The decision to apply a specific treat- [Jones, 1924a, 1924b] or the early treament of
ment program presupposes competence in the enuresis [Mower & Mower, 1938]), a broad
diagnosis of disorders and the analysis of movement started only in the middle of the
problem constellations. The mutual completion century when two conditions came together:
of classificatory diagnosis and problem analysis (i) The enormous productivity of basic re-
is therefore the basis for rational indication search on learning theory explications for
decisions in behavior therapy. The explicit clinical phenomena had become obvious (e.g.,
question for the optimal therapeutic method Mowrer's two-factor theory of phobias, re-
for a given disorder as well as the offer of search on experimental neurosis, Solomon
concrete alternatives for disorder or problem- and Wynne's work on traumatic conditioning,
oriented indication decisions are specific Dollard and Miller's experiments on originally
characteristics of modern behavior therapy. psychoanalytic concepts). These findings de-
Examples of the various mental disorders for manded for clinical application and testing.
which treatment programs have been developed (ii) There were strong criticisms of the low
can be taken from Table 1 and Table 3. efficacy of the then available psychotherapeutic
(i.e., psychoanalytic) methods and their poor
empirical basis (e.g., Eysenck's criticism of
6.02.3 HISTORICAL DEVELOPMENT OF psychoanalysis [Eysenck, 1952]). Such a funda-
BEHAVIOR THERAPY mental critique immediately posed the question
6.02.3.1 Situation at Onset and Precursors of alternatives. These of course were regarded
especially critically by those who had been
Knowledge of the past may help under- attacked before and thus received particular
standing of the present. Behavior therapy attention.
Historical Development of Behavior Therapy 33
It was at this time that research groups in inducing stimuli with increasing intensity, that
South Africa, England, and the USA at first is, in hierachical order (ªfear hierarchyº).
independently reported great successes with In extending his results to humans, Wolpe
learning theory-based methods in the treatment primarily considered three response domains
of anxiety and other clinical problems. Together for reciprocal inhibition: sexual, assertive, and
with the two other named conditions these relaxation responses. Most widely employable
startling outcomes of the new, at first experi- seemed a modified version of Jacobson's (1938)
mental methods gave the impulse for a devel- progressive muscle relaxation. Wolpe believed
opment whose breadth and dynamic until today relaxation and eating to lead to similar
have no parallel in psychotherapy. neurophysiological effects. In order to reduce
fear responses by reciprocal inhibition, Wolpe
6.02.3.2 The ªFounding Periodº first taught his patients progressive muscle
relaxation and then encouraged them to go
While England and the USA are widely through their feared situations step by step
regarded as the origin of behavior therapy, the while staying in the relaxed state. Originally
contribution of South Africa is still under- Wolpe used exposure in vivo (i.e., in real life
estimated although this is where many of the situations), but then he employed imagined
founding personalities of behavior therapy situations (in sensu) because these were easier to
started their careers. The first publication of realize and were better controllable. In addition,
the term ªbehaviour therapyº in a scientific patients completed comprehensive homework
journal took place in the South African Medical in vivo (i.e., practiced in their natural environ-
Journal (Lazarus, 1958). Since the end of the ment) between therapeutic sessions. He called
1940s and during the 1950s Joseph Wolpe tried this approach ªsystematic desensitizationº and
to bring together learning theory and neuro- described it in his classical book Psychotherapy
physiology at the University of Witwatersrand. by reciprocal inhibition, (Wolpe, 1958) that was
This was consistent with his training as a published by Stanford University Press in the
physician with central interest in learning USA after a recommendation by Albert
psychology. Wolpe had been influenced by Bandura. Systematic desensitization probably
the American work of Masserman on experi- still is the most famous treatment method in
mental neurosis and by Salter on ªself-asser- behavior therapy, although there are now more
tiveness training.º In South Africa he worked effective methods for many clinical problems
with psychologists such as Stanley Rachman and reciprocal inhibition theory has been
and Arnold Lazarus who together with their shaken by contradicting evidence. Wolpe's
compatriotes G. Terence Wilson and Isaac formulation of a theory on the basis of testable
Marks belong to the most prominent founders hypotheses with the goal of clearly defined
of behavior therapy. In such groups experi- treatment strategies for minutely described
mental research was discussed and therapy clinical applications had a tremendous impact
sessions were ªsupervisedº and observed on the development of behavior therapy.
through one-way mirrors. Many of the important actors of the South
In his research on ªexperimental neurosisº in African behavioral scene pursued their work in
cats, Wolpe developed new techniques to the United States and England. Wolpe's pub-
eliminate experimentally induced fear and lications came at a time where the efficacy of the
avoidance. Based upon the notion that condi- psychoanalytic approach was severely attacked.
tioned fear and food intake should be antag- Especially Eysenck's (1959) controversial argu-
onistic and thus inhibit each other reciprocally, ment that the success rates of psychotherapy
he assumed that feeding could be used to reduce (then largely identical to psychoanalytic ther-
fears resulting from specific situations. Wolpe apy) were not better than spontaneous remis-
demostrated this successfully in his animal sion, that is, the percentage of improved
subjects by systematically decreasing the dis- patients was not higher with psychotherapy
tance between the feeding place and the place than without it, yielded vehement debates. It is
where fear had been conditioned using electric not surpsing then that Eysenck's department
shocks. In an article entitled without modesty was the European cradle of behavior therapy.
Reciprocal inhibition as the central basis of Head of the famous Institute of Psychiatry at
psychotherapy, Wolpe (1954) postulated reci- the Maudsley Hospital in London was Aubrey
procal inhibition as a universal principle: ªFear Lewis, a strong advocate of the relevance of
reduction is achieved if fear inducing stimuli are psychological research for psychiatry. In 1950
presented together with stimuli that produce a he made Eysenck the first head of a psycholo-
dominant antagonistic response to fear (i.e., gical department of this leading institution.
reciprocal inhibition).º To make certain that Soon collaborators such as Gwynne Jones,
inhibition was stronger, he presented fear- Victor Meyer, Aubrey Yates, or M. B. Shapiro
were interested in the application of condition- ment were the publications by Shapiro (1961) on
ing theories to psychological problems. This experimental single-case methodology. Clinical
group knew Wolpe's publications more than the single-case experiments typically involve a series
operant work of Lindsley in the USA. Single of measurements of a clinically relevant variable
case experiments and theoretical seminars that in regular intervals (time series). At a predete-
were at first purely diagnostical were soon mined point in this series an intervention is
extended to therapeutic topics. As early as 1957 made and the effect of this intervention is then
Meyer emphasized the importance of a good assessed by looking at the changes in the
relationship between therapist and patient for measured variable. In this way, the effects of
exercises in vivo. most intervention strategies can be determined.
The first clinical application of a behavioral Later, complex experimental designs were
approach at the Maudsley Hospital occurred developed (see Barlow & Hersen, 1984) that
more or less by chance (Schorr, 1995). When made it possible to apply single-case experi-
drinking coffee with a medical student, Gwynne ments to a large number of clinical and scientific
Jones and M. B. Shapiro discussed a patient that problems as a part of everyday work. Although
had been treated psychotherapeutically without this method is not limited to the behavioral
success. The young dancer was unable to work approach, it has a close tie to it and plays an
because she had to urinate very frequently important role in its ongoing development.
which had in the meantime led to secondary At the end of the 1950s and the beginning of
anxiety responses and a lack of self-confidence. the 1960s behavior therapy offered already a
The conversation led to the idea to attempt a broad scope of therapeutic methods on the basis
new treatment approach using conditioning of experimental psychology. These became fast
techniques. A combination of systematic de- known outside the inner circle of active
sensitization in vivo for the main complaint and researchers. Important for the dissemination
a stepwise training in vivo for the other anxiety were publications and the international ap-
responses outside of the hospital brought a pointments of ªfounding personalitiesº to
treatment success that proved durable at five- universities and clinical institutions. The vo-
year follow-up (Jones, 1956, 1960). lume Behaviour therapy and the neuroses edited
In the 1960s the application of learning-based by Eysenck in 1960 already included contribu-
treatments was advanced at the Maudsley tions from the USA, the UK, South Africa, and
Hospital by Rachman, who had before worked Czechoslovakia. In the early 1960s, Wolpe,
with Wolpe and now had good contact with the Lazarus, and Cyril Franks accepted professor-
psychiatric side of the Maudsley (personal com- ships in the USA. In 1963 Eysenck founded the
munication by H. J. Eysenck, September 1995). journal Behaviour Research and Therapy, whose
Rachman played a central role in the develop- editor later became Rachman. At this time the
ment of aversion therapy (Rachman & Teasdale, new movement became known under the name
1969) (which was soon to be given up again), ªbehavior therapy,º although alternative terms
behavioral medicine, and the treatment of (e.g., ªbehavior modificationº which was pre-
obsessive-compulsive disorder (Rachman & ferred by the promoters of operant methods)
Hodgson, 1980). Other colleagues in hospitals existed and some prominent participants simply
in London and Oxford (Warneford Hospital) wanted to add explanatory elements to the
such as Gelder, Marks, and Mathews developed traditional ªpsychotherapyº (e.g., Wolpe's
and tested exposure treatments for phobias. At ªpsychotherapy by reciprocal inhibitionº).
the same time American researchers such as It is hardly possible to determine who really
Davison (1968) investigated the process of first coined the term behavior therapy. This is
desensitization and other anxiety reduction primarily due to the fact that there was no single
techniques in detail. They came to the conclusion ªfounding father.º Instead, the behavioral
that exposure in vivo was the most important and approach developed as a relatively broad move-
effective component of treatment (see also ment simultaneously in several places in South
Kazdin & Wilcoxon, 1976). An important Africa, England, and the USA. For the same
reason why behavioral approaches gained reason, only a starting period but not a single
influence in the treatment of anxiety-related starting date can be given. The development as a
problems so fast was the fact that their efficacy broad movement based upon empirical psychol-
was tested systematically in controlled studies. ogy differentiates behavior therapy from all
One such study that set standards for psy- other forms of psychotherapy. These were
chotherapy research was presented by Paul in regularly ªinventedº by single charismatic
1966. personalities with more or less distance to
In addition to the treatment of anxiety, such scientific psychology. It may be argued that
diverse problems as writer's cramp, tics, and behavior therapy's type of origin already
stuttering were addressed. An important ele- contains the nucleus for the development of a
broad ªbasic orientationº rather than a narrow nication between the two groups was rather
ªtherapy school.º At the same time this origin reluctant. Integration of the operant methods
can also be seen as an important protection into the behavior therapy movement was not
against dogmatic immobility and as an impetus unproblematic. It was only since the 1970s that
for continuous development. Better than the the terms behavior therapy and behavior
invention of the term, its dissemination can be modification became regarded as more or less
attributed. Its widespread usage goes back prim- equivalent. Until today, a small group of strictly
arily to Hans J. Eysenck and Arnold Lazarus. operant researchers have kept their own tradi-
While Wolpe rejected such a ªbrand name,º they tion outside of the more clinically oriented
postulated that the large differences to the behavior therapy (ªapplied behavior analysisº).
traditional approaches should be underlined All in all, the relevance of operant methods is
with a new name. The first printed appearance of frequently overestimated, especially from out-
Behaviour therapy was authored by Lazarus in side behavior therapy, although they are only
1958. The first public usage of the new term, rarely applied as sole treatment methods. They
however, was made by Eysenck in a talk entitled do, however, have a firm place in parts of
Learning theory and behaviour therapy (pub- behavior therapy, for instance in the treatment
lished in 1959). Here, the highly confrontative of childhood behavioral problems, mental
marketing strategy of Eysenck is clearly visible: retardation, or chronically institutionalized
he combined a fundamental and partly polem- patients. Studies such as those on ªtoken
ical critique of traditional methods with a partly economiesº in long-term institutionalized men-
overly optimistic view of the new approach. tal patients underlined the importance of social
reinforcement for change in general, for long-
6.02.3.3 The Influence of Operant Approaches term generalization and the maintenance of
desired or acceptable behaviors (Ayllon & Azrin,
The mainstream of behavior therapy at first 1968). More recent research, however, has
developed outside of America where at that time yielded doubts about the theoretical basis of
the operant approach was very popular in token economies and other methods that were
psychology. This is perhaps one reason why the originally conceptualized as purely operant
potential clinical applications of operant meth- techniques. Thus, it has been shown that social
ods were hardly acknowledged. Another reason feedback and specific guidelines for action were
was the fact that operant researchers did not the most important factors in such programs,
come out of the clinical sector. Skinner himself more important than the ªtokensº themselves or
never worked clinically. But even those of his the reinforcers they represented. In spite of this,
followers that moved into the clinical world the development of token economy programs
typically did not limit themselves to it. Instead, was important beyond their immediate applica-
they always saw other fields such as education, tions because they underlined the relevance of a
economy, or administration as important areas comprehensive approach in rehabilitation. The
of applications for their methods. usage of structured social reinforcement (e.g.,
In the late 1950s, Skinner and Lindsley praise) has been accepted more widely in clinical
described the potential applications of operant practice than the usage of tokens or symbols for
methods. Corresponding therapies, however, reinforcement. Emphasizing the role of chan-
were only conducted in the 1960s and at first ging and structuring social interactions has for
with children and mentally handicapped adults. instance strong importance in the treatment of
The first clinical applications are related to the schizophrenic patients (Fallon, Boyd, & McGill,
names of Charles Ferster, Ivar Lovaas, Donald 1984; Hahlweg, DuÈrr, & MuÈller, 1994). Another
Baer, Sidney Bijou, Leonard Krasner, Leonard very important influence of the operant ap-
Ullman, Nathan Azrin, and T. Ayllon. The proach was the acceptance of functional analysis
ªoperant groupº had constructed their own (behavior or problem analysis). Behavior ana-
network of relationships and publication out- lysis in behavior therapy is based upon the
lets. They utilized their proper, highly technical Skinnerian concept of explaining behavior by
terminology and restricted themselves to the studying the conditions under which it emerged.
narrow approach of Skinnerian psychology The relevance of living conditions, environ-
whose clinical application they called applied mental factors, and social relationships had
behavioral analysis or behavior modification. before been underestimated or even overlooked.
The term behavior therapy was rejected as much
as the term ªpatientº for the addressee of their 6.02.3.4 Consolidation and Broadening of Scope
interventions. Eysenck, Rachman, Wolpe, and
their colleagues became aware of the clinical With the founding of clinical/scientific socie-
work of the American operant school only in the ties devoted to behavior therapy a first period of
early and mid-1960s. Even after that commu- consolidation of the stormy development began.
The American AABT was founded in 1966 as the relaxation treatments) and new methods were
Association for the Advancement of Behavioral introduced or disseminated (e.g., social skills
Therapies. Later, the plural was given trainings in groups, behavioral treatment of
up and the name was changed to Association depression). The treatment of sexual dysfunc-
for the Advancement of Behavior Therapy. The tions developed less from behavioral research on
first members of AABT came largely from these disorders, but rather from the work of
two groups: first, a primarily academic group Masters and Johnson (1970) on the physiology
of scientist-clinicians interested in ªclinical of sexual responses. Even though this approach
psychology as an experimental science,º who had an independent origin, it shared the
had been organized in a subgroup of the emphasis on concrete operationalization of
American Psychological Association (Division treatment strategies and on empirical testing
12, Section 3); second, a primarily clinically with behavior therapy. This was the main reason
active group that had been influenced directly by for its rapid integration into behavior therapy
founding personalities of behavior therapy such which gives further testimony to the concept of
as Wolpe, Franks, Salter, or Reyna. Cyril behavior therapy as a broad basic orientation.
Franks was elected as the first president of A significant broadening of the behavioral
AABT, the vice-president was Wolpe. The approach was introduced by the development of
council of the society consisted of equal numbers behavioral medicine. The term had originally
of scientists and practitioners. While AABT been used by Birk (1973) to describe the
experienced an enormous increase in member- application of biofeedback to medical problems.
ship, the European sibling society EABT In biofeedback, patients are given immediate
(European Association of Behaviour Therapy) information about relevant changes in their
was founded in 1971. The intiative for this was physiological system (e.g., by auditory or visual
taken by Johannes C. Brengelmann, who had feedback) in order to acquire control even of
spent long years with Eysenck in England and in involuntary physiological responses. Behavioral
the USA. He returned in 1967 to Germany and medicine soon extended to a substantially larger
became Director at the Max-Planck-Institute of field. Today, it encompasses all applications of
Psychiatry in Munich and head of its psycho- psychological knowledge and techniques to
logical department. Brengelmann, who was the purely somatic problems (e.g., burnings, tumor
decisive personality for the development of pain), disorders of possible partial psychological
behavior therapy in Germany and several other origin (e.g., irritable bowel syndrome), or risk
European countries, became the first president factors (e.g., smoking, nutrition, physical ex-
of EABT. Before this, individual national ercise). Behavioral medicine has become a
societies for behavior therapy had been founded largely interdisciplinary movement that has
in several European countries (e.g., the German developed a multitude of applications.
society was founded in 1968 and one year later Another important development consisted of
had already 450 members). The members of overcoming the narrow borders of the behavior-
EABT at first came from similar sources as those istic heritage of the early learning theory-based
of AABT, namely academic researchers and behavior therapy. Strictly speaking, Mowrer's
practioners with a close contact to founding (1947) two-factor theory which was frequently
centers such as London or Munich. The used to explain phobias already contained a
ªofficialº founding of EABT took place during departure from behaviorism. The notion of
a congress in Munich, which was attended by negative reinforcement of phobic avoidance by
1200 participants from 14 countries. anxiety reduction implied the concept of anxiety
Consolidation was also furthered by a rapidly as an internal, ªmentalº state that was not
increasing flood of research works and publica- directly observable. In addition, Eysenck and
tions in journals or books and by the imple- others had always accepted an influence of
mentation of the first teaching or training biological and genetic factors. Especially im-
centers. In the 1970s behavior therapy therefore portant for the advancement of behavior
came to a first stage of maturity while there were therapy, however, was the acceptance of the
still many new techniques being developed, so-called ªthree-systems approach.º Peter Lang,
tested and refined. Toward the end of the decade, Rachman, and others (Hodgson & Rachman,
most of these treatment approaches were 1974; Lang, 1993; Rachman & Hodgson, 1974)
internationally accepted. Behavioral methods argued that psychological reactions and pro-
were the treatment of choice for such diverse blems related to them needed to be seen as
problems as phobias, obsessions and compul- multidimensional, loosely connected responses
sions, sexual dysfunctions, or the rehabilitation systems acting on different ªlevels.º The most
of chronic mental patients. At the same time popular classification differentiates between a
existing techniques were further developed (e.g., subjective/cognitive, a behavioral, and a phy-
shortening of the duration of exposure or siological level of response. Although these
response systems are interconnected, they do not background. In clinical practice, this approach
necessarily have to change in the same direction, was accepted by an increasing number of
at the same time, to the same degree etc., a behavior therapists. A further important devel-
phenomenon that has been termed ªdesyn- opment at this time was the attempt to apply
chronyº by behavioral writers (Hodgson & behavioral methods to other mental disorders,
Rachman, 1974; Rachman & Hodgson, 1974). especially depression. After Ferster (1965) and
This alternative to a uniform view of Lewinsohn (1974) had assumed that depression
psychological problems was important because resulted from a lack of positive reinforcement,
it allowed explanation of the wide variation in first treatment approaches consisted of elevat-
the symptom patterns reported by the patients. ing the rate of positive reinforcement. The
It also permitted a more systematic and precise success of this method stayed limited, perhaps
assessment of treatment outcomes. In addition, because patients typically judged efforts and
differential outcomes could now be observed. outcomes negatively even if they attempted to
Thus, relaxation exercises might influence the comply with the treatment regimen. This made
physiological aspects of a problem more readily the relevance of cognitive factors increasingly
than the behavioral or subjective problems. clear. The lack of satisfaction with the strictly
Moreover, the relevance of experience was more behavioral techniques led to the attempt to add
strongly acknowledged although a largely cognitive methods to them. This opened the way
behavioristic, response-oriented language con- for a more systematic integration of these
tinued to be used. The threefold classification by methods and for the development of new
Lang or Rachman has frequently been criti- cognitive-behavioral approaches.
cized. There is indeed no a priori reason to
assume three levels rather than four or more
response systems. Some authors argue that it 6.02.3.5 Integration of Behavioral and Cognitive
would be better to distinguish between a Approaches
cognitive and an affective system which would
result in a four-systems approach. Other Lang's theory of three relatively independent
authors such as Fahrenberg (1987) pointed to response systems had strengthened the basis for
the large body of findings that question the the acceptance of cognitive ideas within the
assumption of a unitarian, homogenous phy- behavioral approach. Empirical psychology
siological level. Nevertheless, it was important had already acknowledged the relevance of
to overcome the early monistic and one- cognitive variables to such a degree that the
dimensional view of human responses. Today, ªcognitive turning-pointº had been passed by
a ªmany-systems approachº with its emphasis most actors. The delayed integration of the
on desynchrony is generally accepted in spite of cognitive dimension into behavior therapy
the ongoing discussion about the best classifica- probably had its roots in the continuing
tion of response systems. In clinical practice, influence of Watson's rejection of introspection
Lang's (1993) three-systems approach is the and in the experiences with its abuse potential in
established (although simplified) standard. ªtalking curesº of limited success. In addition,
At the end of the 1970s the usefulness of the polemical position toward other psy-
behavior therapy was widely accepted. Because chotherapeutic approaches that behavior thera-
researchers now no longer had to prove the pists typically took in the founding phase made
general efficacy of their approach, some of them it difficult to abandon identity-producing
directed their attention to those patients that boundaries. Bandura's work on vicarious
were not helped by behavior therapy, even when learning, however, had directed the attention
it was applied correctly. These studies culmi- even of behavior therapists toward cognitive
nated in the first scientific psychotherapeutic factors. The fact that people were able to learn
book on the failures of treatment by Foa and new behaviors by observing the behavior of
Emmelkamp (1983). Already in the late 1960s others even without being reinforced themselves
and early 1970s a beginning discontentment transgressed traditional learning theory. Later
with the strict behavioristic guidelines of the on, Bandura developed a model of self-regula-
early years was apparent. Especially Lazarus tion that he termed ªself-efficacy.º This ap-
(1971) criticized the ªmechanisticº terminology proach postulates that any conscious behavior
of early behavior therapy. He argued that the change is based on the subject's conviction of its
multitude of behavior therapy's interventions capacity to perform this concrete behavior. The
could not be explained by learning theory alone. rigorous empirical methodology of Bandura's
Instead, he proposed the introduction of work facilitated its acceptance even by research-
ªbroad-spectrum behavior therapyº that should ers and practitioners who had originally been
include all techniques with empirically demon- behavioristically oriented. In addition, the
strated efficacy regardless of their theoretical increasing interest in the concept of self-control
had an important influence on the development 6.02.2. There are, however, also critics of this
of behavior therapy. People observe themselves, convergence (for instance, Krasner's ªparadigm
judge their own performance, and reinforce (or lost,º that eloquently mourns for the loss of the
punish) themselves accordingly. On each of clear operant paradigm).
these levels, problems may arise and lead to
clinical states such as depressed mood. Research
into these phenomena led to the investigation of 6.02.3.6 Continuous Development and the
cognitive constructs including attribution and Future
self-instruction.
Perhaps the first cognitive therapeutic method Modern cognitive-behavioral therapy at-
that gained acceptance in behavior therapy was tempts a true integration of its components. It
Meichenbaum's (1975) self-instruction training. aims to help patients recognize their individual
The popularity of this approach was bolstered by structure of distorted thinking and inadequate
its simple, consistent theoretical basis and its behavior. Systematic cognitive restructuring
resemblance with the operant concept of ªcover- and carefully structured behavioral tasks are
ants.º Meichenbaum argued that behavior designed to help the patients in dealing with
changes can be induced by changing the problems in both domains. In the meantime,
instructions that patients give themselves. cognitive-behavioral treatment programs have
Inadequate and negative thoughts should be been developed for most mental disorders that
transformed into more adequate statements. It is occur in everyday practice. In some instances it
not by chance, that self-instruction training was is the behavioral part, in others the cognitive
first implemented in the treatent of impulsive part that dominates. Moreover, a host of
children. The inner monologue and the thinking findings from process research points out that
of these children were termed self-verbalizations even in classical behavioral treatments such as
and seen as equal to the coverants in operant exposure in vivo cognitive processes may
terminology. The artifical term ªcoverantº was contribute as central mechanisms of change.
derived from ªcovertº and ªoperantº and thus The behavioral approach is still characterized
denoted covert operant behavior. With the help by rapid change. One of the more important
of this terminology, mental contents were new achievements is the development of specific
ªsmuggledº into the operant movement. treatment programs for a rapidly increasing
In contrast, independent cognitive ap- number of disorders or specific problem con-
proaches that had developed outside of behavior stellations. These are frequently represented in
therapy encountered much more hesitation. the form of concrete therapy manuals in order
Although Beck's (1967) cognitive therapy and to facilitate practical implementation. Therapy
Ellis' (1962) rational-emotive therapy originated manuals were originally used in treatment
in the 1960s, it took many years before they grew research as a mean to ensure treatment integrity
together with the behavioral movement. Until in clinical studies. They were quickly dissemi-
late in the 1970s cognitive and behavioral nated in the practice sector, because they made
approaches were seen as separate ªschools.º therapeutic methods more concrete and thus
This led to sometimes inadequate differentia- accessible to the broad public of practitioners.
tions or to attempts to prove that the other Texts on psychotherapy had for a long time
school was ªin realityº using methods of one's been overly abstract and often lacked any
own school. It was only in the 1980s that the two concrete descriptions or guidelines of what
movements converged and only in 1995 the first needed to be done in practice. Manuals with
joint ªWorld Congress of Behavioural and concrete guidelines therefore fulfilled an im-
Cognitive Therapiesº was held in Copenhagen. portant need. The positive view of treatment
Integration also became obvious in the renaming manuals is reflected among others by the criteria
of EABT into EABCT (European Association for empirically validated treatments that were
for Behavioural and Cognitive Therapies) in established by the Task Force on Promotion
1992 on the occasion of the 22nd Congress of the and Dissemination of Psychological Procedures
ªoldº EABT in Coimbra, Portugal. A common of the American Psychological Association
basis between the cognitive and the traditional (APA). Their criteria see the existence of a
behavioral movement were the methodological manual as one precondition for any therapy
standards emphasizing operationalization, ex- method to be accepted as scientifically vali-
perimental research, and systematic testing of dated. Another important line of development
efficacy on the one hand and the rational, is ongoing professionalization of behavior
pragmatic orientation on the other. Today, therapy in routine patient care and therapist
cognitive, behavioral, and cognitive-behavioral training. Training issues are especially relevant
treatments together form the broad basic in most European countries where a number of
therapeutic orientation alluded to in Section different private and public training models
Empirical Status of Behavior Therapy 39
coexist. Several countries have passed laws therefore only briefly summarize the findings on
regulating the practical application of psy- behavior therapy.
chotherapy including behavior therapy. These How should treatment studies be aggregated?
laws have important implications for research The most important approaches to the problem
and practice as do managed care and health of secondary analysis used so far can roughly be
maintenance organizations in the USA. classified into three groups:
The historical perspective shows what devel- (i) Narrative summaries. Here, the collected
opments have led to acknowledgment of the studies on a topic are simply interpreted more or
benefit that the behavioral approach has for less intuitively and a personal judgment of their
most mental disorders. The vast amount of outcomes is given. A severe disadvantage of this
change in the past leads to the prediction that approach is its lack of objectivity. It has been
the future of behavior therapy will also be shown that most people distort their judgment
characterized by major modifications of present in the light of pre-existing biases. Moreover, the
methods and concepts. This is facilitated by the rapidly increasing number of publications
fact that ongoing research and development are makes it very difficult for any individual to
major attributes of behavior therapy. But even have a complete overview.
in its present form the behavioral approach (ii) Box-score method. Based on the justified
offers effective help for patients as well as a criticisms of narrative summaries, this method
valuable basis for the understanding of mental attempts a more systematic and quantitative
disorders. The empirical basis for these asser- approach. It simply consists of counting the
tions is the topic of the following section. number of statistically significant effects that
were obtained in the different studies. This,
however, is subject to so many limitations that
6.02.4 EMPIRICAL STATUS OF the approach is of dubious utility. Especially
BEHAVIOR THERAPY important is the problem of low statistical
6.02.4.1 Problems in Empirically Approaching power in most psychotherapy studies. The
Efficacy difficulties in recruiting patients and conducting
the studies typically result in small sample sizes
Psychotherapy research has moved from one that do not allow the detection of even clinically
difficulty to another: after a long period with a relevant effects with sufficient certainty. In
massive lack of empirical findings we now have addition, simply looking at statistical signifi-
the opposite problem. Largely due to the cance overlooks information about the strength
behavioral approach there are now so many of the effects (ªclinical significanceº). More-
studies on the outcome and process of psy- over, it is unacceptable to give studies with
chotherapy that it has become hard for anyone widely varying methodological quality or very
to keep track. Aggregating findings across a different outcome criteria equal weight.
vast number of different studies is a problem in (iii) Meta-analysis. This last problem also
itself (see below). Without any doubt behavior applies to meta-analysis, which otherwise
therapy is by far the most intensely researched avoids the power problem of the box-score
type of psychotherapy (Grawe, 1992; Grawe, method. Meta-analysis is at present the most
Donnati, & Bernauer, 1994). For behavioral objective method for aggregating findings from
and cognitive methods there have been over 10 different studies. It starts by calculating ªeffect
times more published studies than for all other sizesº for each measure taken in each study.
types of psychotherapy together (Grawe et al., Effect sizes express by how many standard
1994). Even some individual behavioral meth- deviations the mean of two groups (e.g., treat-
ods have been put to test more frequently than ment and control group) or of one group at two
the whole group of psychoanalytic or huma- times (e.g., pre- and post-therapy) differ. This
nistic approaches, respectively. In addition, standardization makes different measures di-
behavioral methods have been applied to the rectly comparable, even across separate studies.
broadest spectrum of mental disorders with In a second step, all calculated effect sizes are
typically positive results. However, such a then averaged to yield one ªintegratedº effect
general statement needs to be specified because size as a global index of therapy outcome. As
ªautomaticº generalization across all disorders stated above, a criticism is that the methodo-
is senseless. Instead, individual disorders have logical quality of the studies or even clinical
to be regarded separately. Of course a larger relevance (e.g., clinical vs. analogue sample)
number of studies does not necessarily imply typically are not taken into account. Of course,
better efficacy compared to other treatments. one could introduce weights for methodological
A more detailed assessment is thus needed quality or set methodological criteria for inclu-
although the whole body of psychotherapy sion into the meta-analysis. However, this
research cannot be summarized here. I will introduces, a subjective element and thereby
affects objectivity that together with its quanti- In these studies, behavioral methods have
tative nature is a great advantage of the method. proved effective in achieving the immediate
The utility of meta-analytic results has been goals of treatment as well as generalized
challenged by referring to the fact that fre- benefits that most of the individual techniques
quently very different studies are thrown to- have to be given the status of empirically
gether (ªcomparing apples and pearsº). In spite validated therapy methods (Grawe, 1992).
of these criticisms, meta-analysis has estab- Especially well researched are exposure techni-
lished itself as an objective statistical method ques that were frequently applied to agorapho-
for the aggregation of heterogenous findings bia, obsessive-compulsive disorder, and specific
across separate studies. phobias. They led almost always to massive
improvement of the target symptoms, while the
effects on general well-being and other masures
6.02.4.2 Results of Outcome Research were somewhat smaller. Well established is also
the effect of systematic desensitization in
The most comprehensive and differentiated treating anxiety disorders. A very broad range
analysis of outcome research so far has been of effects was found for social skills training
published by Grawe and co-workers (1994). that almost regularly achieved significant
Shortly after this work appeared in print, it positive changes beyond the target symptoms.
became a standard for any discussion of the Broad efficacy was also found for cognitive
topic. In contrast to earlier meta-analyses, methods such as Beck's treatment for depres-
Grawe et al. analyzed the methodological sion, rational-emotive therapy, Meichenbaum's
quality of the studies, took the different types self-instruction, and stress-inocculation train-
of outcome measures into account, and in- ings or problem-solving treatments. Studies
cluded all controlled studies published until revealed not only a very broad range of clinical
1983 regardless of language, country of origin, applications but also some degree of specific
or publication outlet in their thorough analysis. relations between certain treatments and in-
Table 2 shows the number of controlled studies dividual disorders. Thus, anxiety disorders were
that Grawe found for the different classes of most frequently treated with exposure-based
therapy methods and for the individual methods followed by systematic desensitization
cognitive-behavioral techniques. Table 3 shows and cognitive methods. ªThe application of
for what types of disorders behavioral methods behavior therapy in clinical practice is thus
have been tested. based on a broad spectrum of treatment
Table 2 The number of controlled studies that were found by Grawe et al. in their meta-analysis of published
therapy outcome studies.
Number of Number of
Different types of therapy studies Only cognitive-behavioral methods studies
Cognitive-behavioral methods 567 Social skills training 74

Progressive muscle relaxationa 66 Exposure 62
Autogenic training 14 Biofeedback 62
Hypnosis 19 Systematic desensitization 56
Meditation 15 Cognitive coping methods 38
Psychoanalytic short-term treatments 27 Aversion therapies 31
Psychoanalytic therapy 12 Problem-solving therapies 25
Long-term psychoanalysis (Freud) and each 0 Sexual therapy 22
analytic therapy (Jung)
Client-centered therapy 35 Lewinsohn's therapy of depression 17
Gestalt therapy 7 Rational-emotive therapy 17
Psychodrama and transactional analysis each 6 Beck's therapy of depression 16
Marital therapy 35 Alcoholism programs 14
Family therapy 18 Paradoxical intention 10
Interpersonal therapy 10 Broad-spectrum behavior therapy 8
a
The classifiaction of progressive muscle relaxation is controversial. It can be subsumed under behavioral methods (of which it typically was
part) or counted as a separate entity. We chose the later approach in order to give more detailed information. Other methods not mentioned in
the table were either not specfied clearly enough (unspecified humanistic therapies N = 11, encounter-groups N = 9, unspecified
psychodynamic therapies N = 8, psychodynamic therapies with drugs N = 13, eclecticistic therapies N = 22) or counted only 1±3 studies
(music therapy, body therapy, dance/art therapy, bioenergetics, Ich-Analyse, Individual therapy (Adler), Katathymes Bilderleben,
Daseinsanalyse). Because many behavioral studies used combinations of methods, the numbers in the right column do not add to the
total given in the left column for cognitive-behavioral methods.
Table 3 Types of mental disorders for which behavioral methods have been tested empirically in controlled treatment studies based on Grawe's 1994 meta-analysis. For each
disorder, the number of studies published until 1983 is given.
Somatic V-codes for

Organic Substance Disorders states with states without
Therapeutic Childhood mental abuse Other Affective Anxiety Sexual of impulse Disorders psychological mental Additional
method disorders disorders disorders Schizophrenia psychoses disorders disorders dysfunctions cntrol of adaptation factors disorders codes
Cognitive 10 1 18 19 1 1 5 15 12 20
Various 10 11 1 16 5 2 2 3 28 9
Biofeedback 7 2 1 1 9 1 2 57 2
Systematic 2 2 3 1 37 12 4 4 6
desensitization
Operant 4 1 6 11 3 4 4 3 1 4 11 19
Social skills 1 7 4 4 7 9 4 3 6 3 22
training
Exposure 1 1 1 57 1 1 3
Aversion 3 1 24 1 2 910 1 1
Modeling 1 3 5 1 11 2 2 3 3 18
Self-control 10 12 1 4 4 1 4 1 7
Covert 7 1 2 7 1 2 11
conditioning
Speech therapy 7 1 1
Table 4 Results of meta-analyses comparing the efficacy of different types of psychotherapy. Because of the
low number of studies, psychodynamic and humanistic methods were typically grouped together.
Psychodynamic/ Cognitive-behavioral Direct comparisons within

humanistic methods methods one study
Meta-analysis Mean effect sizes Mean effect sizes Difference between effect sizes
Smith et al. (1980) 0.64 1.03 70.49

Shapiro & Shapiro (1982) 0.40 1.08 70.53
Nicholson & Berman (1983) 0.29 0.75 70.44
Wittmann & Matt (1986) 0.30/0.25 0.50
Grawe et al. (1994) 0.83 1.21 only direct comparisons
(psychoanalytic methods)
Grawe et al. (1994) 0.87 1.13 only direct comparisons
(client-centered methods)a
a
Without the study of Angulo (1983; quoted in Grawe et al., 1994), whose results represent clear outliers (effect sizes for behavior therapy about
8, for client-centered therapy about 4, patients with obsessive-compulsive symptoms).
methods with proven efficacy. With a clear publications that were in addition analyzed
distance to other types of treatment, behavior with a different algorithm; Grawe et al. (1994)
therapy can therefore claim to have proven its analyzed only direct comparisons, etc.). In
effectiveness sufficiently for playing a promi- every meta-analysis cognitive-behavioral meth-
nent role in psychotherapeutic mental health ods fared better than other treatments. This
careº (Grawe, 1992, p. 139). result holds up after methodological problems
In addition to the general statements on the (such as restriction to direct comparisons,
efficacy of behavior therapy, Grawe et al. consideration of different types of outcome
(1994) also analyzed all studies directly com- measures, limitation to certain types of dis-
paring behavior therapy with psychoanalytic, orders, liberal or conservative inclusion criteria,
client-centered, or systemic treatments that etc.) have been addressed.
were published until 1991. Further inclusion An important alternative to the meta-analytic
criteria were at least three outcome measures, at approach was proposed by the Task Force on
least six hours of treatment duration, similar Promotion and Dissemination of Psychological
duration (ªdosageº) of the different treatment Procedures of the APA (1995). Their approach
conditions (unless differences were explicitly takes into consideration one major criticism of
justified on a theoretical basis), and the most meta-analytic studies published so far,
publication of means and standard deviations namely the neglect of the differences between
of outcome measures. In this way, they found the various mental disorders. It is inadequate to
41 studies with a total of 1401 effect sizes. The exclude the type of disorder treated in outcome
large number of effect sizes results from the research. The assumption that disorders as
great number of treatment conditions and different as alcoholism, sexual dysfunctions,
outcome measures. The direct comparisons agoraphobia, or schizophrenia can be treated by
underlined impressively the results reported the same method regardless of the specific
above for the behavior therapy studies: The characteristics of the disorder is unrealistic. The
comparison with psychoanalytic (19 studies, question for efficacy therefore always has to
215 outcome measures, 487 individual compar- address clearly defined categories of problems
isons), client-centered (10 studies, 133 outcome or disorders. In addition, the APA Task Force
measures, 723 individual comparisons), and considered treatment integrity. In contrast to,
family-therapy methods (3 studies, 18 outcome for instance, pharmacological treatments, psy-
measures, 40 individual comparisons) always chotherapeutic approaches need to clarify what
yielded a clear-cut superiority of behavioral concrete actions are included under such labels
approaches. These results are in line with those as ªbehavior therapyº or ªclient-centered
of earlier meta-analyses as can be seen in Table therapy.º For this purpose the treatment
4. This table summarizes the effect sizes that manuals mentioned above are pivotal. More-
have been calculated in the different meta- over, the criteria reflect the notion that
analyses. Because the calculatory basis differed controlled treatment studies may be the best
considerably across meta-analyses, the compar- but not the only valid source of empirical
ison within each meta-analytic study should information on treatment outcomes. For long-
primarily be regarded (thus Wittmann and term treatments these studies have traditionally
Matt (1986) included only German-language been regarded as being hard or even impossible
Empirical Status of Behavior Therapy 43
to perform. Single-case experimental studies 6.02.4.3 Consequences of Research Findings

offer an alternative if they fulfill basic metho-
dological standards. Another requirement was The behavioral approach therefore very
that positive reports on a treatment's efficacy clearly deserves the certificate of being the best
should come from more than one independent validated psychotherapeutic orientation. In
center, thus avoiding situations where the addition to the large number of studies on the
ªfounderº of a therapy keeps finding his efficacy of the individual treatment methods, the
treatment perfectly useful. On the basis of these vast body of knowledge collected by clinical
and additional considerations, minimal criteria psychology and its neighboring disciplines on
for empirically validated treatments were estab- the etiology, diagnosis, and epidemiology of
lished. In addition, the Task Force made a mental disorders contributes to this success. For
difference between ªwell-establishedº and most disorders, specific treatment programs
ªprobably efficaciousº methods. The criteria tailored to their individual characteristics have
are listed in Table 5. A first, still provisorial been developed and tested. Behavioral treat-
listing of treatments that fulfill the two sets of ments can therefore have very different contents
criteria is given in Table 6. depending on the nature of the problem to be
The results of the APA Task Force resemble treated. In principle, the superior empirical basis
those discussed above for the meta-analytic for behavioral treatments should imply that
approach. The vast majority of treatments listed these methods should play a central role in
in Table 6 come from the cognitive-behavioral psychotherapeutic patient care. However, one
approach. This is even more important, because cannot derive from the research findings that
the proposal for the APA criteria which also behavioral methods are the only ones that
accepts single-case studies as valid data origi- should be applied. There are still no ª100%
nated from an psychoanalytically oriented methodsº for most mental disorders. Even the
member of the Task Force (1995). Using a best treatments yield a certain amount of
quite different approach, this Task Force failures. As long as this is the case, we need a
composed of members with various therapeutic broad spectrum of treatment options that
orientations came to the same result as Grawe address different facets of the problematic
et al. (1994) or the other quoted meta-analyses. structures. Yet this does not mean that every
Table 5 Criteria for empirically validated treatments established by the APA Task Force on Promotion and
Dissemination of Psychological Procedures (1995, 1998).
Well-established treatments
I. At least two good between group design experiments demonstrating efficacy in one or more of the
following ways:
A. Superior to pill or psychological placebo or to another treatment
B. Equivalent to an already established treatment in experiments with adequate statistical power
(about 30 per group)
OR
II. A large series of single case design experiments demonstrating efficacy
These experiments must have:
A. Used good experimental designs and
B. Compared the intervention to another treatment as in I.A
FURTHER CRITERIA FOR BOTH I AND II:
III. Experiments must be conducted with treatment manuals
IV. Characteristics of the client samples must be clearly specified
V. Effects must have been demonstrated by at least two different investigators or investigatory teams
Probably efficacious treatments
I. Two experiments showing that the treatment is more effective than a waiting-list control group
OR
II. One or more experiments meeting the well-established treatment citeria I, III, and IV, but not V
OR
III. A small series of single case design experiments otherwise meeting well-established criteria II, III, and IV
Table 6 Treatments named by the APA Task Force on Promotion and

Dissemination of Psychological Procedures as examples of their criteria
for empirical validation (1995).
Well-established treatments
Cognitive therapy for depression
Behavior modification for developmental disorders
Behavior modification for enuresis and encopresis
Behavior therapy for headache and irritable bowel syndrome
Behavior therapy for orgasm and erectile dysfunctions
Behavioral marital therapy
Cognitive-behavioral therapy for chronic pain
Cognitive-behavioral therapy for panic disorder and agoraphobia
Cognitive-behavioral therapy for generalized anxiety disorder
Exposure therapy for phobias and post-traumatic stress disorder
Exposure and response prevention for obsessive-compulsive disorder
Psychoeducative family intervention for schizophrenia
Cognitive-behavioral group therapy for social phobia
Interpersonal therapy for bulimia
Interpersonal therapy for depression
Training programs for parents with behavior problems
Systematic desensitization for specific phobias
Token economy programs
Probably efficacious treatments
Applied relaxation for panic disorder
Psychodynamic short-term therapy
Behavior modification for sexual offenders
Dialectical behavior therapy for borderline personality disorder
Emotion centered couples therapy
Habit reversal training and habit control training
Psychoeducational therapy of depression
therapist can do what they want regardless of the of lay personnel such as relatives or friends also
research findings. We need to ask ourselves how belongs here.
to choose the most promising method for each (ii) If self-help fails or is insufficient, how-
individual case or for the rank order of the ever, professional help should be sought. Here
different approaches that could possibly be we can distinguish between general, nonspecific
applied to the case. These decisions need to take counseling or supportive measures on the one
into account other variables such as the hand and a specfic therapy for the mental
motivation and personality of the patient, the disorder on the other. As long as there are no
possible existence of comorbidity, or the avail- acute crises, suicidal ideation, active psychoses,
ability of treatments or therapists. In addition, it or a long history of failed treatments, generalists
has to be clarified whether and when the patient such as the family physician can try to achieve
should be transferred to another specialist and improvement using nonspecific measures.
what role primary care physicians and self-help (iii) If this does not lead to clear-cut im-
measures could play. As a general rule, measures provement or the listed conditions are not met,
with the best cost-benefit ratio should be tried a specific treatment of the mental disorder
first. These considerations lead to the proposal should be started as fast as possible in most
of more or less rational ªsequential modelsº for cases, beacuse most mental disorders otherwise
clinical practice (Margraf, 1996) such as the one have a high risk of chronification. The decision
detailed in Table 7. Of course, the model between the competing psychological or phar-
delineated below represents an abridgement, macological treatments should not simply be
that in clinical practice needs to be specified based on the personal preference of therapist or
according to disorders and other factors. patient. Instead, it should consider probability
The ideas behind this sequential model can be of success, cost-benefit ratio, durability of
summarized as follows. treatment outcomes, and the other conditions
(i) It is generally better if the patient is able to discussed above (e.g., availability).
solve his problems himself. Therefore, given an (iv) Among psychological treatments,
adequate motivation the person should be cognitive-behavioral methods should typically
encouraged to try self-help measures. The input (for most disorders) form the first line of
Problems and Criticisms of Behavior Therapy 45
Table 7 A sequential model for choosing treatment interventions in

clinical practice.
1. Self-help, lay interventions

2. Advice, counseling, supportive therapy
3. Specific treatment of the mental disorder
3.1. Behavior therapy
3.2. Other psychotherapeutic and pharmacological interventions
3.3. Long-term interventions after treatment failures
Source: Margraf (1996).
intervention because their efficacy is best vali- behavioral movement started. Moreover, it is
dated and they have a favorable cost-benefit very difficult for patients or other physicians or
ratio. Only if this does not lead to sufficient psychologists to judge the competence of any
success should other types of psychotherapy be given colleague. Many national health insurance
applied because these typically are less well schemes (or the lack of them) are responsible for
established empirically and often involve great- limitations to the availability of competent
er expense (e.g., longer duration). behavior therapy. Another aspect are the wishes
(v) Similar considerations apply to the and prejudices of the patients that often come
choice of pharmacological methods. Here, the with strong feelings about their treatment. These
questions of durability of outcomes or relapse are frequently conveyed by media, popular
after drug withdrawal and of side effects (cost- literature, friends, or relatives. Some decline
benefit ratio) may lead to critical reflections. any notion of pharmacological help (ªhow can
(vi) In some cases, the necessity of long-term pills help with psychological distress?º), others
support may arise. This could for instance be the definitely do not want to be treated by
case if intensive attempts have not led to psychotherapy (ªI am not crazy!,º ªThey only
clinically significant improvement. Here its is dig in the past!º). Some people, especially with
important to convey to the patient that he or she an academic background, have powerful con-
is not alone and to avoid making the patient victions even with respect to the specific kind of
ªguiltyº for failure. Of course, it needs to be psychotherapy (ªin depth,º ªthorough,º ªex-
clarified whether all promising treatment meth- plain everythingº). All of these points together
ods have been attempted competently. In clinical may be responsible for the fact that behavior
practice, one frequently sees cases where due to therapy is applied far less frequently than one
their training or theoretical orientation, care should assume on the basis of the research
providers used only a narrow part of the total findings and the productive publication activ-
spectrum of treatment methods. In these cases, ities of its proponents.
transfer to another specialist is often helpful. In
other cases, however, all that is left is to convey to
the patient a realistic notion of his chances for 6.02.5.1 Misunderstandings About Behavior
recovery and to support him in dealing with the Therapy
chronic aspects of his condition. An important obstacle to the dissemination
of behavioral methods have been several
6.02.5 PROBLEMS AND CRITICISMS OF obstinate misunderstandings about its nature
BEHAVIOR THERAPY or techniques (Baer & Minichiello, 1990; Yates,
1977). Some of these misconceptions will be
Like any other human endeavor, behavior briefly addressed here.
therapy has its share of problems. These are for (i) Behavior therapy does not lead to symp-
instance the treatment failures that may occur tom substitution.
even with good motivation on the patient's side (ii) The experience of strong emotions during
and optimal application on the therapist's side. exposure (e.g., in phobias, grief reactions, post-
Here, research is called for in order to ameliorate traumatic disorders, or eating disorders) is not
success rates, attrition, etc. Other important dangerous for the patients.
problems of behavior therapy lie in limiting (iii) The thoughts and feelings of the patients
setting factors such as lack of information of are not ignored. Instead, they are addressed
patients and professionals or obstinate misun- directly by a multitude of therapeutic interven-
derstandings about the behavioral approach. In tions.
addition, the availability of well-trained beha- (iv) Modern behavior therapy does not as-
vior therapists is a major problem in most parts sume that all mental disorders have been
of the world, even in those countries where the acquired by simple conditioning processes.
(v) The use of medication is not generally numbers of relaxation methods (including
incompatible with behavioral interventions. hypnosis and autogenic training) and ªtalking
Inasmuch as these misunderstandings are curesº (i.e., primarily psychoanalytic or client-
being clarified and together with the mounting centered methods), while cognitive-behavioral
reception of the results of psychotherapy re- methods accounted for only 1% of all treatment
search, a growing interest in behavioral meth- cases. In view of this fact, it may seem less
ods can be observed. But even today, the lack of surprising that patients on the whole were not
well-trained specialists is a major problem. very satisfied with their treatment successes. For
any type of treatment, the proportion reporting
durable improvement was not attained even in
6.02.5.2 Scientifically Well Established, one-third of respondents. The lowest success
Practically Neglected? rate was given for psychotherapy with only 14%
of respondents reporting lasting success (com-
A remarkable example of the underutilization pared to 29% for drugs!). Of course, these
of behavioral methods is given by the treatment results are limited by the fact that they are based
of anxiety disorders. If anything, these disorders on the patients' classification of the treatment
should be a primary area of application for received. However, assessment of treatments
behavioral methods. However, procedures such was not simply limited to giving labels such as
as exposure in vivo are apparently given only to ªbehavior therapyº or ªclient-centered ther-
a small minority of afflicted persons. Taylor apyº that may be unknown to many patients.
et al. (1989) studied a large sample of patients Instead we gave brief descriptions of various
with anxiety disorders that had applied for treatment methods (e.g., ªexposing yourself
treatment to the anxiety disorders clinic at systematically to feared situations or objectsº).
Stanford University School of Medicine. In any case, this study makes it possible to
Although the region surrounding the clinic generalize from the findings from patients
was densely populated with care providers, they seeking treatment to the general public.
found that less than 10% of agoraphobic
patients had been given a trial of exposure.
One criticism of this study can be seen in the 6.02.5.3 Current Criticisms of Behavior Therapy
fact that the nonrepresentative sample consisted
of self-selected patients searching treatment. In addition to the problems caused by
However, we recently found the same effect in a misunderstandings, misapplications, or the lack
sample 3000 people representative of the Ger- of application, there are several criticisms that
man adult population (Margraf, 1996; Margraf apply to behavior therapy in its current form. In
& Poldrack, in press). The study investigated the my opinion, behavior therapy at least partly has
prevalence of clinical anxiety in the general not addressed some of these criticisms well
population using the Beck Anxiety Inventory enough, which should make its proponents
using a cut-off score from clinical anxiety more modest.
research. In face-to-face interviews, subjects (i) Theory and practice frequently do not
who reported anxiety were asked whether (and overlap very well (Eysenck & Martin, 1987;
if so, how) they had been treated for their O'Donoghue & Krasner, 1995). For instance,
anxiety problem. Results showed that even with exposure methods have a well-established effi-
the broadest definition of treatment only 40% cacy in the treatment of phobias, but the theory
of all afflicted persons had received some kind upon which they are based (two-factor theory,
of treatment and that primary care physicians habituation) are outdated in their classical form.
were by far the most frequent care providers In the same vein, functional behavior analysis
(82% of all treated patients). Genuine specia- classifies problematic into operant and respon-
lists such as clinical psychologists (3%) or dent types although it is quite clear that most
psychiatrists (6%) together performed fewer clinical problems are neither one nor the other.
treatments than other somatic physicians (17%, (ii) Because its treatment methods are most
multiple responses possible). With respect to the often disorder-specific and rely strongly on the
treatments used, there was a remarkable empirical knowledge about these disorders,
discrepancy between drugs (roughly 90% of behavior therapy has neglected unspecific or
all patients, multiple responses possible) and diffuse complaints or problem constellations.
nonspecific advice (roughly 75%) on the one The guidelines for dealing with the problem of
hand and psychotherapy (17%) on the other. In comorbidity (common occurrence of more than
addition, an elevated rate of inpatient treatment one disorder, which is the rule rather than the
(10%) became apparent. exception) are sparse and often unsatisfactory.
Yet the most impressive result to us was that (iii) There are hardly any approaches to the
psychotherapy consisted with roughly equal problems of counseling, although this forms a
References 47
large part of the work not only in couseling (v) develop prevention programs; and
centers but (to a lesser degree) also in psy- (vi) routine evaluation and quality assur-
chotherapy. How should one work through ance.
inadequate feelings of guilt after separation, In dealing with these challenges we need to
deal with leaving-home situations, educational avoid the two contradictory dangers of trivia-
problems, existential problems, etc.? lizing or medicalizing psychological problems.
(iv) The strong emphasis on change together Many psychological problems of a transitory or
with the explicit induction of hope for improve- clearly subclinical nature should not be medi-
ment has not only positive consequences be- calized, that is, they should not be declared
cause there are limits for change and some ªillnessesº requiring treatment (ªfor every bad
situations should not not be changed at all feeling a therapyº). On the other hand, full-
(Wilson, 1996). An example of this problem is blown mental disorders may not be trivialized
behavioral marital therapy. Not all partner- and thereby be withdrawn from adequate and
ships can be optimally restructured, even in necessary treatments (ªdepressed people simply
well-functioning partnerships there may be need to get their act togetherº). As a rule, all
instances where the partners do not agree and concerned parties will only profit from a move-
that should not be changed. There is a danger of ment away from ideology and toward a more
promising too much or things that cannot be empirical approach in psychotherapy. Hope-
attained (see the discussion of therapeutic goals fully, the current debates on psychotherapy
in Section 6.02.2.3). research will contribute to that process.
(v) The ªclassicalº criticism of early behavior
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Wittmann, W. W., & Matt, G. E. (1986). Meta-Analyse als try, 7, 1±5.
Integration von Forschungsergebnissen am Beispiel Woolfolk, A. E., Woolfolk, R. L., & Wilson, G. T. (1977).
deutschsprachifer Arbeiten zur Effektivitat von Psy- A rose by any other name . . . : Labeling bias and
chotherapie. Psychologische Rundschau, 37, 20±40. attitudes toward behavior modification. Journal of
Wolpe, J. (1954). Reciprocal inhibition as the main basis of Consulting and Clinical Psychology, 45, 184±191.
psychotherapeutic effects. Archives of Neurological Psy- Yates, A. J. (1970). Behavior therapy. New York: Wiley.
chiatry, 72, 205±226. Yates, A. J. (1977). Falsche Auffassungen uÈber die
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Verhaltenstherapie: Ein Standpunkt. In H. Westmeyer
Stanford, CA: Stanford University Press. & N. Hoffmann (Eds.), Verhaltenstherapie: Grundlegende
Wolpe, J. (1976). Behavior therapy and its malcontents. 1. Texte. Hamburg: Hoffmann & Campe.
6.03
Cognitive Therapy
IVY-MARIE BLACKBURN
Cognitive Therapy Centre, Saint Nicholas Hospital, Newcastle upon
Tyne, UK and University of Durham, UK
6.03.2 PRINCIPLES OF COGNITIVE THEORY OF EMOTION 52
6.03.2.1 A.T. Beck (Early Model) 52
6.03.2.2 The Evolution of Beck's Model 53
6.03.2.2.1 Personality variables 54
6.03.2.3 Interpersonal Processes 56
6.03.2.4 Constructivism 56
6.03.2.5 Information Processing and Cognitive Science 57
6.03.2.6 Other Cognitive Approaches 60
6.03.2.6.1 Rational-emotive therapy 60
6.03.2.6.2 Self-instructional training 62
6.03.2.6.3 Hopelessness theory of depression 62
6.03.3 APPLICATION OF COGNITIVE THERAPY 63
6.03.3.1 General Principles of Cognitive Therapy 63
6.03.3.2 Treatment Methods 67
6.03.3.2.1 Behavioral methods 67
6.03.3.2.2 Cognitive methods 68
6.03.3.3 Developments 75
6.03.4 PROCESS OF COGNITIVE THERAPY 76
6.03.4.1 Mediators of Change in Cognitive Therapy 76
6.03.4.2 Moderators of Change in Cognitive Therapy 78
6.03.5 EFFICACY 78
6.03.6 CONCLUSION 79
6.03.1 INTRODUCTION from the two embattled camps of psycho-

analysis and behaviorism (Blackburn, 1986;
Nearly 40 years have elapsed since the early Salkovskis, 1986).
work of Beck and Ellis in the late 1950s and As with all ªnewº ideas, the cognitive move-
early 1960s in cognitive approaches to the ment did not arise de novo. Several influences
treatment of emotional disorders. Both were within the general field of psychology and from
reacting against classical psychoanalysis in clinical practice have been acknowledged, in
which they had been trained and thus started particular Piaget (1972) who described the
what has been termed ªThe cognitive revolu- hierarchical structuring of knowledge; the ego
tionº (Dember, 1974) which, however, is analysts (e.g., Adler, 1936; Horney, 1950) who
probably best conceptualized as an evolution stressed patterns of thinking regarding the self
51
52 Cognitive Therapy
and the world as central to understanding concept of basic structures or schemata derived
feelings and behavior; Kelly (1955) who was a from cognitive science (Bartlett, 1932; Neisser,
real ancestor in his descriptions of personal 1976; Piaget, 1950) These represent the sum of
constructs; Arnold (1960) and Lazarus (1966) previous experiences, serving as templates that
who stressed the role of cognition in their direct attention, influence encoding and inter-
theories of emotion. pretation of stimuli, and facilitate recall. In
Be it revolution or evolution, it can certainly depression, the schemata reflect themes of loss
be asserted that cognitive therapy has been a and of self deficiency, for example, ªunless I do
most successful movement, in view of the highly everything perfectly, I am worthlessº or ªunless
prolific research literature, the number of I do everything to please others, they will reject
specialized journals, the demands for training me.º It is noteworthy that at this stage of the
courses in cognitive therapy, and continuous theory, no differentiation was made between
refinement of the underlying theoretical princi- conditional schemata or basic assumptions,
ples. The strength of cognitive therapy from its rules, and attitudes on the one hand, and
inception has been its emphasis on empirical unconditional schemata or core beliefs on the
backing. This tradition continues, both in other, for example, ªI am inadequateº or ªI am
experimental studies and in clinical outcome unlovable.º An example linking the three
studies, and, consequently, the theory has not elements described above would be:
remained static, being also informed by ad-
vances in related areas of study, namely Schema: (conditional)
cognitive science, social science, and biology. ªIf people do not like me, I cannot be happyº
This chapter will consider the key principles Stimulus:
of the cognitive theory of emotion and how they ªA friend does not telephone as promisedº
apply to cognitive treatments. The range of
approaches and recent developments will be ;
discussed. Interpretation: (Content of
thought expressed in
negative automatic
6.03.2 PRINCIPLES OF COGNITIVE thoughts)
THEORY OF EMOTION ªShe does not like meº (arbitrary
inference
6.03.2.1 A.T. Beck (Early Model) ªNobody likes meº personalization)
(magnification)
Beck's early work (1963, 1967), related to (overgeneralization)
ªI shall always be alone and
thinking style in depression and later expanded
miserableº
to other emotional disorders (1976). He de-
scribed the typical negative content of thought ;
in depression as a pervasive negative view of the
self, of the environment, and of the future (the Feeling:
negative cognitive triad), expressed in auto- ªDown in the dumpsº
matic, habitual thoughts in reaction to trigger
stimuli. The negative automatic thoughts are Once the negative feeling is triggered, it is
maintained by various processing errors with a likely to feed forward and lead to other stimuli
negative bias (arbitrary inferences, selective being interpreted negatively in accordance with
abstractions, personalizations, overgeneraliza- the schema which has been activated and which
tions, minimizations, and magnifications). becomes progressively more widely applied to
These processing errors do not differ necessarily inappropriate stimuli. Similarly, maladaptive
from the type of processing errors made by non- behaviors, such as ruminations and inactivity,
depressed individuals (labeled heuristics by become preponderant and increase the inci-
Kahnneman, Slovic, & Tversky, 1982), the dence of negative automatic thoughts and the
difference being in the direction of the bias, corresponding dysthymic moods. The typical
which is usually positive in the nondepressed, schemata, beliefs, rules, and attitudes reflect
expressed as a self-serving bias (Taylor & themes of love, approval, entitlement, omnipo-
Brown, 1988). The consequence of processing tence, perfectionism, autonomy, and achieve-
information with a negative bias is a congruent ment, as measured by the Dysfunctional
negative emotion. Thus, the information pro- Attitude Scale (DAS) which was developed
cessing model of emotional disorders was set in specially to assess this aspect of Beck's theory
a straightforward vertical or unidirectional (Weissman & Beck, 1978)
model, which has since been reviewed. To The cognitive model of the anxiety disorders
explain why some individuals process informa- (Beck, 1976; Beck & Emery, 1985) followed the
tion with such unhelpful biases, Beck evoked the same principles, emphasizing specific patterns
Principles of Cognitive Theory of Emotion 53
of thinking which differentiate these disorders in anxiety (Hibbert, 1984; Butler & Mathews,
from depression. Beck, Laude, and Bohnert 1983), the causative role of cognitions, and the
(1974), in two studies designed to elicit thoughts specificity of cognitive therapy, relative to
and visual imagery associated with anxiety, antidepressants medication, in changing cogni-
found that anxious patients experience threa- tions have not been demonstrated (Blackburn &
tening thoughts or images which often precede Bishop, 1983; Simons, Garfield, & Murphy,
attacks of anxiety. These thoughts relate to 1984).
anticipated or visualized danger and extreme Regarding particular biases in information
vulnerability. It was apparent that imagery was processing, in general, studies support an
important in anxiety, an aspect that had not attentional bias in anxiety and a memory bias
been stressed in depression, but which is in depression (Dalgleish & Watts, 1990; Mogg
emphasized in cognitive therapy (Edwards, et al., 1991; Wells & Matthews, 1994; Williams,
1989) The content of thought in anxiety was Watts, MacLeod, & Mathews, 1988) Williams
found to relate to an anxiogenic triad; seeing the et al. (1988) proposed that ªanxiety involves
world as threatening, the self as vulnerable, and biased allocation of attention at the preattentive
the future as uncontrollable. This approach was stage, and depression involves biased use of
similar to that of Lazarus (1966) who distin- mnemonic cueing at the elaborative stageº
guished between two cognitive processes in (p. 181). Indeed, several studies have found
anxiety, namely primary and secondary apprai- no bias in memory for threat words in anxious
sal. Primary appraisal relates to an individual's subjects, inter alia (MacLeod, 1991; Mineka,
evaluation of a situation as dangerous and 1992; Mogg, Mathews, & Weinman, 1987),
threatening, whereas secondary appraisal re- while there is substantial evidence of a negative
lates to the evaluation of the self as not having bias in retrieval process in depression (Blaney,
the internal and/or external resources to deal 1986; Breslow, Kocsis, & Belkin 1991; Teasdale
with that situation. & Russell, 1983). The extensive research in
The processing errors in anxiety do not differ information processing in depression and the
essentially from those described in depression, anxiety disorders (reviewed by Wells & Mat-
but the schemata are likely to be different, thews, 1994; Williams et al., 1988) directly
referring to themes of personal vulnerability, of inform cognitive therapy as applied to these
unpredictability, and of threat, for example, ªIf disorders to date.
I feel anxious, this means I have no control of The structural aspect of the cognitive model
myselfº or ªI must always be on my guard, if not of the emotional disorders has been the most
something awful will happen.º elusive of its components to put to experimental
As in depression, the dysfunctional schemata validation. As alluded to above, the term
are self- or world-referent; they tend to be rigid ªschemaº has been used differently by different
and undifferentiated. These characteristics have authors and a reliable and valid methodology to
been taken as implying that they have been measure and assess schemata is not well
learnt in early childhood and continue to established.
survive through the process of assimilation, In the conceptualization of cases for the
rather than accommodation (Piaget, 1977). development of cognitive treatment strategies
(Persons, 1989), it is usual to differentiate
between conditional schemata or basic assump-
6.03.2.2 The Evolution of Beck's Model tions and core or unconditional schemata.
Thus, in the example given in the previous
The implications of the original model were section, the core schema may be ªI am
of a causative link between cognitions and unlovableº leading to the conditional schema
emotions, assigning primacy to cognitions. This ªIf people do not like me, I cannot be happyº
was challenged by Zajonc (1980) and Rachman and the rule ªI must do everything people ask of
(1981, 1984). Beck (1987) restated his approach me.º The same basic or core schema may lead to
more clearly, emphasizing that negative cogni- the conditional schema ªIf people get close to
tions are inherent to depression, as delusions are me and get to know me, they will reject meº
inherent to psychosis, and that, therefore, they leading to the rule ªI must avoid close relation-
cannot be conceptualized as causing depression, shipsº. This differentiation developed from the
as delusions cannot be said to cause psychosis. extension of cognitive therapy to personality
Negative cognitions are one side of the coin and disorders (Beck, Freeman, et al., 1990; Young,
biological changes the other side. While re- 1990); from greater emphasis on the role of
search findings have given ample evidence for a conceptualization in treatment (Blackburn,
negative content of thought in depression Twaddle, et al., 1996); and from the clinical
(Haaga, Dyck, & Ernst, 1991) and thoughts observation that although there seems to be a
relating to personal danger and inability to cope limited range of themes in basic schemata, there
is a wide variety of conditional schemata leading self-referent adjectives are likely to reflect core
to different behaviors, different ways of con- schemata. Figure 1 describes the generic model
structing the self and the environment, different of the emotional disorders, following Beck's
mood states, and different disorders. The approach as developed from the original model,
typical themes of core schemata relate to differentiating core schemata and basic assump-
personal worth (e.g., I am worthless/useless), tions. In Figure 2, the application of the generic
to moral worth (I am bad/evil), to abnormality model to a specific case is shown in a case
(I am a freak/abnormal/different), and to formulation, where good as well as depressed
personal ability (I am incapable/inadequate). periods can be understood through the indivi-
Examples of how these different levels of the dual's core schema.
structural aspect of cognitive theory are used in
case conceptualizations will be given in Section
6.04.3.
6.03.2.2.1 Personality variables
The standard assessment tool of underlying
cognitive structures remains the DAS, Form A, A further development in the area of
(Weissman & Beck, 1978), a 40-item, seven- vulnerability to depression has been the deli-
point scales questionnaire which primarily is neation of higher-order, more stable personality
aimed at measuring the presence and intensity characteristics which may determine the content
of belief in conditional schemata in depression. of dysfunctional schemata. These have been
A questionnaire by Young (1990) attempts to defined as sociotropy and autonomy by Beck
measure core schemata (Early Maladaptive and his colleagues (Beck, 1983; Beck, Epstein, &
Schemata in Young's terminology), but the Harrison, 1983). An overly sociotropic indivi-
scale has not been validated adequately. Several duals is described as socially dependent, highly
studies, using the DAS, have shown that level of invested in positive interchange with others,
dysfunctional attitudes discriminates between valuing above all acceptance, intimacy, support,
depressed subjects and controls, inter alia and guidance. In contrast, an overly autono-
(Blackburn, Jones, & Lewin, 1986; Hamilton mous individual is highly invested in indepen-
& Abramson, 1983) and at post-treatment, dent functioning, mobility, freedom, choice,
predicts future levels of depression (Rush, achievement, and the integrity of the personal
Weissenberger, & Eaves, 1986; Simons, Mur- domain.
phy, Levine, & Wetzel, 1986). However, not A specially constructed scale, the sociotropy-
surprisingly according to Beck's theory, the level autonomy scale (SAS; Beck et al., 1983) consists
of dysfunctional attitudes decreases markedly of 60 items rated on five-point scales. A large
with remission and becomes indistinguishable number of studies have been conducted (Black-
from normal level (Blackburn, Roxborough, burn, 1996; Clark & Beck, 1991; Gilbert &
Muir, Glabus, & Blackwood, 1990; Simons et al., Reynolds, 1990; Hammen, Ellicott, Gitlin, &
1984). Jamison, 1989; Moore & Blackburn, 1994;
The endorsement of self-referent adjectives is Robins, 1990) indicating that sociotropy is
another method of assessing the self-schema related to vulnerability to interpersonal life
(Segal, 1988), which is more in line with the events, to level of depressive symptoms, to level
definition of schemata in cognitive psychology. of neuroticism, and to the subscale of the DAS
Using this methodology, Teasdale and collea- which measures social approval. Moreover,
gues (Teasdale, 1988; Teasdale & Dent, 1987) Moore and Blackburn (1996) have shown, in a
found that subjects vulnerable to depression large clinical sample of depressed patients
recall more global self-referent adjectives (e.g., assessed pre- and post-treatment, that socio-
ªpathetic,º ªworthless,º ªstupidº) than never tropy, as assessed by the SAS, is relatively stable
depressed subjects who recall more specific and over time in contrast with level of dysfunctional
milder negative self-referent adjectives (e.g., attitudes as assessed by the DAS. On the other
ªrude,º ªthoughtless,º ªinconsiderateº). The hand, the conceptual validity of autonomy has
number of global negative adjectives endorsed not been demonstrated. It has been shown to be
also predicted level of depression five months only minimally related to level of depression
later in mildly depressed women. Teasdale (Gilbert & Reynolds, 1994; Moore & Black-
(1988) put forward his differential activation burn, 1994, 1996), to correlate poorly with other
hypothesis on the basis of such findings; this measures of independence and not to predict
states that the type of thinking activated in mild- consistently an interaction with negative
dysphoric moods, in combination with high achievement events (Hammen et al., 1989;
neuroticism, a personality variable (Eysenck, Robins & Block, 1988). The autonomy scale
1970) which also affects selective recall of of the SAS is in the process of being revised for
depressed memories, is likely to activate higher new validation studies (Clark, Steer, Beck, &
levels of depression. These globally negative Ross, 1995).
EARLY EXPERIENCE
DYSFUNCTIONAL ASSUMPTIONS SCHEMATA

} PREDISPOSING/
VULNERABILITY
FACTORS
CRITICAL INCIDENT
ASSUMPTIONS ACTIVATED
} PRECIPITATING
FACTORS
MAINTAINING
AUTOMATIC NEGATIVE THOUGHTS } FACTORS
PHYSIOLOGICAL MOTIVATIONAL
AFFECTIVE BEHAVIORAL
} SYMPTOMS
COGNITIVE
Figure 1 Cognitive model of emotional disorders.
Depression: “I am inadequate.” Works hard at school,

This is shameful. (Core schema) university and at keeping a
tenuous relationship going.
Change of job:
Feels deskilled/devalued. “I should be able to cope Has cheated in an
“I’m no good.” – if not people will look examination – guilt.
“I can’t cope.” down at me.” “This is shameful;
“It’s my fault.” “It is shameful to be I’m not as good as Ann.”
seen as not coping.”
Improved work conditions: “I must be well organ- Takes an “easy” subject
Feels good. ised and keep everything at university. The “better”
under control – if not I’m students study medicine
failing.” or science.
Depression: “I am not good enough.”
New job/difficulties at work. “If my personal relation-
“I thought I was doing well, ships go wrong, it is my
they don’t value me – I’m fault.” Depression:
no good.” (Basic assumptions; Examination time –
“All my efforts have come conditional schemata) “I won’t pass, I’m
to nothing.” not good enough.”
Marriage, good job: Depression: Breakdown of

Feels happy. “I have failed.” relationship.
“I’ve put in all this effort for
nothing.”
“I feel dumped, abused.”
“Cannot let anybody know.”
Figure 2 Depression conceptualization (reproduced by permission of Souvenir Press from Cognitive therapy in
action. A practitioner's case-book. Blackburn, Twaddle et al., 1996).
6.03.2.3 Interpersonal Processes emphasizes the active and proactive nature of

all knowing, the operation of tacit or uncon-
It may be that the relationship of sociotropy, scious processes, the complexity of human
and not autonomy, to depression simply reflects experiences, and the need for a developmental,
that interpersonal processes are of particular process-focused approach to knowing. Some of
importance in depression, and possibly in other the proponents of this approach, apart from
emotional disorders. Early descriptions of Mahoney, are Neimeyer (1992, 1993), Guidano
cognitive therapy were criticized for ignoring and Liotti (1983), and Anderson (1990) who are
interpersonal processes (Coyne & Gotlib, 1983). all indebted to Kelly's (1955) personal construct
Safran and Segal (1990) have made a welcome theory. Constructivism is contrasted by these
contribution emphasizing the role of interper- authors to logical positivism and rationalism
sonal factors. They state ªthe individual must which are described as characterizing Beck,
always be understood as part of the interperso- Rush, Shaw, and Emery's (1979) information
nal systems in which he or she is participating. processing model and Ellis' (1962) rational-
Thus, one cannot understand the patients in emotive approach. Neimeyer (1993) considers
therapy independently of the therapistº (p. 5). constructivism to be predicated on a post-
They view the therapeutic relationship as modern epistemology and gives a quote from
central to cognitive therapy, in that it is through Kelly (1977, p. 6) ªwhat we think we know is
the therapeutic relationship that core dysfunc- anchored only in our assumptions, not in the
tional interpersonal schemata can be revealed. bedrock of truth itself, and that world we seek to
The interpersonal schema is defined as a generic understand remains always on the horizons of
cognitive representation of interpersonal events our thoughts,º as representing a quintessen-
which derives from interactions with attach- tially postmodern conclusion.
ment figures of the past and serves to predict Neimeyer (1993) contrasts traditional cogni-
future interactions with these figures and with tive theory and therapy with constructivist
others. The stress on the interpersonal perspec- theory and therapy. In so doing, he gives a
tive has exercised a strong influence on the distorted and narrow view of the Beckian
practice of cognitive therapy, in that more approach, at least in its modern form. He
emphasis is put on the therapeutic relationship interprets Beck et al. (1979) and Ellis (1973) in
and more attention is paid to developmental particular, as equating emotional adjustment
factors, especially in the treatment of person- with rationality (logical empiricism), so that
ality disorders. Issues which might have been when humans deviate from rationality and the
considered as stumbling blocks in therapy, for scientific method, they form distorted views of
example, lack of trust, overdependence, avoid- themselves, their world, and their future, and
ance, and aggression, can now be directly experience dysphoric emotions and emotional
employed to guide formulation and question- disorders. The word ªrationalº may have been
ing. For example, if the patient appears to be emphasized in earlier cognitive theory, but it is
aggressive in therapy, the therapist may com- not now; the term ªdysfunctionalº being
ment: ªIt seems to me that you feel angry with preferred, indicating that thoughts or attitudes
me. Is this how you feel at the moment?º ªIs it are dysfunctional when they have negative
something that I have said or something about consequences, not because they are irrational.
me?º ªIs there some other situation like this These changes in the theory have followed
outside of therapy that made you feel the same?º research findings that indicate, for example,
ªDid this happen in your family?º Thus, the that depressed subjects do not have exclusive
typical socratic questioning or guided discovery negative thoughts (Clifford & Hemsley, 1987),
style of cognitive therapy is used to uncover that depressed subjects choose as many positive
possible core interpersonal schemata, rather as negative adjectives as self-descriptors (Derry
than, perhaps more traditionally, just to elicit & Kuiper, 1981), and that normal controls
the current automatic thoughts so as to show a ratio of 1:17 of negative to positive
revaluate them and to look for disconfirming thoughts. (Schwartz, 1986). Ellis (1993) has
evidence. argued that even rational-emotive therapy
(RET) has never been truly rationalistic,
6.03.2.4 Constructivism although he accepts that he too has moved
from a more rationalistic to a more constructi-
Mahoney (1993) suggests that one of the vist position. Cognitive therapy (Beck et al.,
ªmajor conceptual developments in the cogni- 1979) has, in any case, always used questioning
tive psychotherapies over the past three dec- that stresses the disadvantages of thinking in
adesº has been the differentiation of rationalist certain ways and the advantages of thinking in
and constructivist approaches to cognition. alternative ways, rather than logical vs. illogical
Constructivism or constructive metatheory thinking.
However, it must be acknowledged that a The model suggests that behavior can be
number of the changes in cognitive therapy, as it affected by a variety of sources, by cognitions,
has evolved, have been influenced by the by cognitive structures directly (e.g., uncon-
philosophical stance of constructivist theories. scious routines such as riding a bike), and by
The examination of developmental factors to affective and biochemical factors. The acknowl-
understand the cognitive structures through edgement of other cognitive structures, which
which an individual construes their world, the remain undefined, recognizes that understand-
stress on interpersonal processes, and developing of the cognitive system is still incomplete,
ments in the understanding of information- particularly as regards unconscious structures.
processing to explain individual emotional The model also suggests a generic model for the
reaction, as described in the next section, emotional disorders which can take into
probably reflect constructivist influences. account similarities and differences across
different disorders. For example, in depression
and anxiety, the operation through which
6.03.2.5 Information Processing and Cognitive information is processed may be largely similar,
Science but the content of the cognitive structures and
the cognitive products differ as described in
Cross-fertilization from cognitive science has Section 6.03.2.2. Such a model would evidently
inspired a vast number of ingenious experiments be far too complex to use in therapy. Instead, as
to test various aspects of information processing shown in Figure 4, a simplified generic model
in depression and anxiety disorders, and has giving the same information can be given to
prompted more complex models of information patients (Greenberger & Padesky, 1995). The
processing (Ingram, 1988; Teasdale, 1993; diagram indicates the interactions among all
Teasdale & Barnard, 1993; Wells & Matthews, elements; biology (which includes physiological
1994; Williams et al., 1988). Ingram and and biochemical changes), thoughts (automatic
Kendall (1988, p. 13) present a complex model thoughts, beliefs, attitudes, schemata), emo-
which is adapted in Figure 3. tions, and behavior and stresses that the
These authors attempt to delineate the individual exists within an environment which
ªpattern of relationships among the various triggers their reactions and which reacts to their
components of the cognitive taxonomic system.º reactions.
The diagram indicates that the different com- Bower (1981) presented his influential asso-
ponents which may be involved in information ciative network theory of mood and memory
processing operate in a reciprocal, interactional, which derived experimentally to explain the
and multidirectional fashion. Cognitive struc- relationships between cognition and mood.
ture is defined as the architecture of the system in According to this theory, emotions, as well as
which information is stored and organized. This cognitions and events, are represented in the
would consist of long- and short-term memories, brain/mind by discrete nodes or units which are
sensory memories, and associative networks. linked in an associative network. Thus, an
Cognitive content represents the information emotion can be activated by an appropriate
that is actually stored, that is, the content of the external stimulus or by the activation of other
cognitive structure, for example, semantic and linked nodes in the associative network, for
episodic memory. The term schema, as used in example, a sad memory or some physical
cognitive therapy, is represented by both the sensation. Once activated, a depressed mood
cognitive structure and the cognitive proposi- or an anxious mood will influence future
tion. Cognitive operations represent the various information processing by the spreading of
procedures by which information is processed, activation through the associative network, so
for example, attention, selection, encoding, that events or situations are more likely to be
interpretation, and retrieval. These represent interpreted negatively or as denoting threat and
the various cognitive processes which have been danger. The prediction from Bower's (1981)
found to show particular biases in the emotional paper was of a recriprocal relationship between
disorders (attentional biases in anxiety and mood and thinking, so that there would be
retrieval biases in depression). Cognitive pro- mood state-dependant retrieval (superior recall
ducts represent thoughts, both automatic and of material retrieved in the same mood state as
controlled, and images. Arrows labeled as was present during learning) and mood-con-
operations indicate cognitive processes leading gruent retrieval (increased ease of recall of sad
to cognitive products, whereas arrows not memories when in a depressed mood state).
labeled as operations indicate ªprocedures that These predictions have been confirmed in
may not be primarily cognitive,º for example, several studies using both naturally occurring
the interactions between affective, biochemical, depressed moods (Clark & Teasdale, 1982;
and cognitive factors. Miranda & Persons, 1988; Miranda, Persons, &
STIMULUS
A friend does not telephone
COGNITIVE STRUCTURE
Long- and short-term
memory of past
rejection/loneliness COGNITIVE
PRODUCTS
OTHER Operations COGNITIVE Operations She never calls BEHAVIOR
COGNITIVE PROPOSITION She does not care Crying
STRUCTURES I don’t have the Selective Nobody cares Depressive
necessary qualities to Abstraction It’s awful Rumination
be loved. Life is not Arbitrary I’m too boring
worth living if one is Inference
not loved Overgeneralization
O
pe
Ope
ra
ratio
tio
ns
ns
SENSORY DATA
BIOCHEMICAL
BEHAVIOR Quiet, cold
FACTORS
No stimulation
AFFECTIVE STRUCTURES OTHER ENVIRONMENTAL SOURCES

Sadness, anxiety, anger E.g. other’s behaviors
Figure 3 Information processing model and depression (Source: Ingram and Kendall, 1988).
COGNITIVE STRUCTURE
THOUGHTS
PHYSICAL/ EMOTIONS
BIOLOGY
BEHAVIOR
Figure 4 Generic cognitive model of the emotional disorder (Source: Greenberger & Padesky, 1995).
Buyers, 1990) and in induced moods (Teasdale described briefly because of its potential
& Fogarty, 1979; Teasdale & Taylor, 1981). influence on cognitive therapy.
However, a number of disconfirming findings ICS aims to bring to clinical psychology
have also been reported, as seen in meta- insights derived from cognitive science. Teasdale
analyses and Ucros (1989) and Bower (1987) (1993) considers that Beck's model depends on
concluded that his theory needed revising. lay concepts of cognition where cognitions refer
Bower (1992) has expanded his theory by only to consciously experienced thoughts and
proposing that emotions may activate not only images and schemata to beliefs and assumptions.
isolated semantic concepts, but wider rule-based He considers that research studies and clinical
action plans. observations have higlighted certain problems
Teasdale (1993) finds Bower's theory an with cognitive therapy: cognitive therapy is not
improvement on Beck's theory, for several uniquely more effective than other psychological
reasons: its clearly testable predictions; its treatments (e.g., behavior therapy, Gallagher &
acknowledgement that negative thinking can Thompson, 1982; Interpersonal Psychotherapy,
be an antecedent, as well as a consequence of Elkin et al., 1989); antidepressant medication
depressed affect; its view of depression as an reduces negative thinking to the same extent as
extreme form of the normal effect of mood on cognitive therapy (Simons et al., 1984); there is
information processing, which thus provides an no evidence of dysfunctional assumptions in
alternative view of cognitive vulnerability with- remitted patients (Blackburn et al., 1990); in
out having to evoke the matching of trigger therapy, it sometimes appears that patients can
events with dysfunctinal assumptions and experience emotional reactions without identifi-
schemata; and its ability to explain the main- able negative automatic thoughts; rational
tenance of depression. In short, he considers argument in therapy often appears ineffective
Bower's theory more scientifically sound than in changing emotional responses; and for more
Beck's. However, Teasdale (1993) and Teasdale refractory problems, for example, personality
and Barnard (1993) criticize Bower's theory on disorders, noncognitive methods of treatment
several counts and have put forward an have had to be borrowed from other schools of
alternative theory, the Interacting Cognitive therapy, for example, Gestalt therapy (Beck,
Subsystems (ICS) framework which will be Freeman et al., 1990).
On the other hand, Bower's (1981) model, information processing. This shift in the inter-
according to Teasdale (1993), fails because of relationship between high order mental codes,
the lack of differentiation in the semantic not the activation of a particular cognitive node,
networks which are described. These appear leads to a negative content of thought in the
to represent knowledge in a single format, so form of negative attributions, evaluations, and
that specific concepts and the relationship memories.
between them is not differentiated. Higher Although this model appears at times overly
order of meaning is not explained and, there- complex and abstract, the clear differentiation
fore, no distinction can be made between ªhotº between propositional and implicational levels
cognitions which are associated with a high level of meaning is useful to understand the process
of emotion and ªcoldº cognitions which are of therapy and to make sense of failures and
reported at an intellectual level, without successes in therapy. The central goal of therapy
accompanying emotions. is evidently to change implicational meaning
Teasdale and Barnard (1993) describe ICS as related to depressive or anxious schematic
an information processing model which at- models by substituting alternative patterns of
tempts to take into account all aspects of meaning related to more adaptive schematic
information processing, and thus, probably models. Since this abstract, generic level of
succeed in developing in more detail Ingram meaning is made up of various elements, such as
and Kendall's (1988) model described earlier. specific meanings, bodily state, and sensory
They postulate nine types of information, information, such as tone and volume of voice
encoded in separate mental codes, representing and visual information, changes in any of the
different aspects of experience; for example, elements may bring therapeutic change. Ther-
sensory experience (sensory and proprioceptive apy would thus involve different elements:
codes); regularities in the sensory code patterns change in meanings and/or change in sensory
(intermediate structural description codes); input, adding new elements to an experience
specific and generic levels of meaning (meaning through guided imagery, and paying greater
codes); and information required for effector attention to feelings through the use of emo-
action (effector codes). Each type of informational methods of treatment as used in Gestalt
tion is processed by its own specialized therapy. Interestingly, such therapeutic ap-
subsystem and encoded in separate memory proaches have been adopted in cognitive
stores. Information processing involves the therapy, especially for personality disorders.
transfer of information between subsystems It seems that clinicians inspired by clinical
and its transformation from one mental code to insight have reached the same point as cognitive
another. theorists, although through a different route,
Importantly for cognitive therapy, in the and perhaps without a proper rationale to
ªmeaning codesº two different codes are explain their methods of treatment.
described relating to two highly different levels
of meaning. The propositional code encodes
specific meanings, discrete concepts, and the 6.03.2.6 Other Cognitive Approaches
relationship between them. This is akin to
Bower's semantic network, for example, ªmy Beck's theories in the original form, and as
neighbour is gray haired.º The implicational further developed through research and clinical
code encodes generic, holistic levels of meaning experience, have been the main emphasis in the
which are difficult to convey in language: it previous sections because it is the approach
relates to recurring very high order regularities which has led most clearly to specific methods of
across all information codes. Only this level of treatment which have been tested widely in
meaning is linked directly to emotion, with controlled outcome studies. However, some
implicit meaning content, for example, ªsome- other approaches have also been influential, in
thing wrong.º Implicational meaning has a high particular Ellis' RET, Meichenbaum's self-
level of abstraction; is influenced by contextual instructional training, and clinical develop-
sensory features, for example, facial expression, ments of Seligman's learned helplessness theory
tone of voice, bodily arousal; and represents by Abramson and her colleagues in the hope-
generic features of experience which cannot be lessness theory of depression. These will be
expressed in single sentences. The implicational described briefly in this section.
code represents schematic models of experience
with which mood biases are associated. Thus,
6.03.2.6.1 Rational-emotive therapy
depression is associated with the regeneration of
depression-related schematic models when there Ellis (1989) describes himself as the first
is a shift in the prevailing high-order mental major cognitive-behavioral therapist in view of
models of self and world which dominate his writings and practice dating back to 1957
(Ellis, 1957, 1962). RET, now relabeled REBT Such beliefs have been described in lists of a
(rational-emotive-behavioral therapy), is based dozen to lists of several hundreds specific ones,
on an ªABCº theory of psychopathology, to a few general categories with many exemplars
stating that activating events (A) do not directly (Ellis & Bernard, 1985). Specific questionnaires
cause emotional and behavioral consequences to measure irrational beliefs, such as the Ra-
(C), but that the mediating variable of beliefs (B) tional Belief Inventory (Shorkey & Whiteman,
about these events exercises the major influence 1977) and the Irrational Beliefs Test (Jones,
on feelings and behavior. As such, the theory is 1968) have been criticized for confounding
quite close to Beck's, but the emphasis is clearly irrational beliefs with negative emotions.
on beliefs only, as opposed to different aspects Ellis and Whiteley (1970) make a difference
of cognition, for example, the content, form, between ªelegantº and ªinelegantº RET tech-
and structure of thought. The therapeutic thrust niques. Elegant or preferential RET involves
of RET has, therefore, been on irrational beliefs forceful disputation of the patient's irrational
as the cause of emotional problems. Rational beliefs with the aim of making profound
beliefs are defined as those promoting survival philosophical changes in the patient. However,
and happiness and as likely to find empirical this approach is not suitable for all patients, for
support in the environment, in contrast with example, for those with limited intellectual
irrational beliefs which are unlikely to find resources or with poor motivation. In such cases
empirical support and reflect ªmustsº and other methods, as used in cognitive therapy, are
ªshould.º Rational beliefs will lead to appro- acceptable. This is described as inelegant or
priate negative emotions (sorrow, annoyance, general RET, involving manipulation of envir-
regret) in the face of losses or difficulties, onmental circumstances, teaching coping stra-
whereas irrational beliefs will lead to inap- tegies, and ªpersuading clients that their
propriate negative emotion (depression, ex- perceptions of events are incorrectº (Raitt,
treme anger, guilt). Haaga and Davison 1988, p. 202). Persuasion is, however, definitely
(1993) argue that the definition of rationality not a Beckian method of cognitive therapy which
and irrationality is problematic in that irration- advocates instead the use of inductive methods
ality is not the prerogative of emotionally to guide patients to evaluate their cognitions and
disturbed individuals. Extensive research has make their own discoveries. Ellis (1980), in his
shown that much of the thinking of nondis- comparison of RET and cognitive behavior
turbed people is irrational (Alloy & Abramson, therapy, emphasizes the philosophical stance of
1979; Taylor & Brown, 1988). Irrational beliefs RET which is that: (i) people create their own
in RET are often defined by lists of typical emotional disturbances through irrational, ab-
beliefs which are often encountered in clinical solutistic beliefs; (ii) as people have free-will,
practice (Ellis, 1962), for example: they can choose to disturb themselves or not; (iii)
(i) there is a dire necessity to be loved for to bring about change, active work at modifying
everything one does; thoughts, feelings, and behaviors is necessary;
(ii) certain acts are awful and wicked and (iv) profound philosophical change will bring
people should be punished who perform such about modification in emotional and behavioral
acts; reactions; (v) long-range hedonism is more
(iii) it is horrible when things are not the way healthy than short-term hedonism; and (vi) a
one would like them; scientific outlook, rather than an unscientific
(iv) human misery is externally caused and is religious or mystical outlook, is likely to bring
forced on one by outside people and events; greater emotional health and satisfaction.
(v) if something is or may be dangerous, one He rightly says that such a philosophical
should be terribly upset about it; stance is absent in cognitive behavioral therapy
(vi) it is easier to avoid than face life's which emphasizes evaluation and modification
difficulties and self-responsibilities; of cognitive processes to bring about long-term
(vii) one needs something other or stronger symptomatic changes, instead of deep philoso-
or greater than oneself on which to rely; phical changes.
(viii) one should be thoroughly competent, The efficacy of RET has been tested in a
intelligent, and achieving in all possible aspects; number of studies (Haaga & Davison, 1989;
(ix) because something once strongly af- Kendall, 1984; Zettle & Hayes, 1980), with
fected one's life, it should indefinitely affect it; encouraging results. However, the studies have
(x) one must have certain and perfect control been highly criticized for their poor methodol-
over things; ogy, involving nonclinical samples, no follow-
(xi) human happiness can be achieved by up evaluation, poor outcome measures, no
inertia and inaction; and attempt at measuring treatment adherence, and
(xii) one has no control over one's emotions the lack of differentiation between the two
and one cannot help feeling certain things. versions of RET (Haaga & Davison, 1993).
6.03.2.6.2 Self-instructional training and successive approximation procedures. The

skills which are taught through modeling are:
Self-instructional training (SIT) is the ther- problem definition, focusing attention and
apeutic method described by Meichenbaum response guidance, self-reinforcement, self-eva-
(1977) in cognitive-behavior modification luative coping skills, and error correcting op-
(CBM). As the term indicates, CBM was a tions (I'm doing okay . . . if I make a mistake, I
development of behavior therapy and behavior can correct it and go on more slowly). The same
modification at the time when efforts were being operant conditioning principles of chaining and
made to incorporate cognition as a valid shaping were used over a number of training
variable in behavior therapy (Mahoney, sessions to teach schizophrenic patients to use
1974), because of the growing dissatisfaction complex sets of self-statements.
with the empirical and theoretical basis of The modification of self-talk or of automatic
radical behaviorism. Cognitive-behavior thera- thoughts is central to cognitive therapy of the
pists proposed that cognitions could be viewed emotional disorders in adults, but the specific
as covert behaviors, subject to the same laws of techniques of SIT appear particularly useful for
learning as overt behaviors. Homme (1965) patients with less well-developed verbal skills,
coined the term ªcoverantsº to denote cogni- for example, children, adults with learning
tions as covert operants, in Skinner's language, difficulties, and severely impaired individuals
which are responsive to both external and such as schizophrenic patients. It has also been
internal contingencies and altered by contig- shown to be effective as a version of cognitive-
uous pairings, through covert sensitization behavioral therapy with phobic and anxious
(Cautela, 1973). Meichenbaum (1993) describes patients (Chambless & Gillis, 1993).
the process as ªclient's self-statements and
images were viewed as discriminative stimuli
and as conditioned responses that come to guide 6.03.2.6.3 Hopelessness theory of depression
and control overt behaviorº (p. 202). Following Seligman's theory of learned helplessness
from that, SIT aimed to decondition maladap- (Seligman, 1975; Seligman & Maier, 1967), as
tive patterns of behavior by training in self-talk a model of depression derived from animal
which would establish and strengthen new experiments where uncontrollable shocks were
patterns of behavior and by rehearsing adaptive administered, was criticized for not being an
coping skills. ªThe technology of behavior adequate model for depression in humans. The
therapy, such as modelling, mental rehearsal, model did not appear to reflect the complexity
and contingency manipulations, was used to of human depression and the varied presenta-
alter not only clients' overt behaviors, but also tion of depression. As a result, a reformulated
their thoughts and feelingsº (p. 202) (Meichen- learned helplessness model was proposed by
baum, 1993). Abramson, Seligman, and Teasdale (1978),
Meichenbaum (1977) describes the applica- based on attributional theory, which described
tion of SIT and successful outcomes in a particular type of depression, namely hope-
hyperactive and impulsive children, socially lessness depression. In brief, the theory stated
withdrawn children, adult schizophrenics, and that when an individual makes causal attribu-
in creativity training. An example of SIT with tions which are internal, global, and stable for
impulsive children involves the following steps: negative events, but which are external, specific,
(i) an adult performs the task while talking to and unstable for positive events, expectations
himself out loud (cognitive modeling); are created that highly desired outcomes are
(ii) the child performs the same task under unlikely to occur or that highly aversive out-
the direction of the model's instructions (overt, comes are likely to occur and that the individual
external guidance); has no available response to change the
(iii) the child performs the task while in- likelihood of occurrence of these outcomes.
structing himself or herself aloud (overt self- These expectations and the occurrence of a
guidance); negative event were seen as a sufficient proximal
(iv) the child whispers to himself while he or cause of depression. However, Abramson et al.
she goes through the task (faded, overt self- (1978) were aware of problems in this analysis,
guidance); in that not all highly improbable, but highly
(v) finally, the child performs the task while desired outcomes, will be a sufficient cause of
guiding his or her performance via private depression. For example, it may be desirable to
speech (covert self-instruction). win several million dollars on the weekly lottery,
Over a number of training sessions, the but people do not generally become depressed if
package of self-statements modeled by the they fail to win. There are other characteristics
experimenter and rehearsed by the child is of the desired outcomes, for example, how much
enlarged by the means of response chaining concern exists about them and how possible
Application of Cognitive Therapy 63
they are, which may determine whether their (Beck, Wright, Newman, & Liese, 1993); for
nonoccurrence is a sufficient proximal cause of bipolar disorder (Basco & Rush, 1996); and for
depression. inpatients (Wright, Thase, Beck, & Gudgate,
Abramson, Alloy, and Metalsky (1988) have 1993). In this chapter, the general characteristics
clarified and revised the helplessness theory of of cognitive therapy are described and attention
depression. They describe it as a diathesis stress is focused on developments which have evolved
model, relevant to one hypothesized subtype of following the theoretical developments de-
depression. The hopelessness theory specifies scribed above.
not only a proximal sufficient cause, but also Cognitive therapy was first developed as a
potential distal causes. A negative life event is short-term treatment of 12±16 weeks, for
interpreted by an individual who has a unipolar depressed outpatients (Beck et al.,
depressogenic attributional style (the diathesis) 1979). The extension of its application to an ever
as due to stable, internal, global factors and high increasing range of conditions and of disorders
importance is attached to the event. These may be a cause for concern for some, but need
attributions may be modulated by situational not be surprising in view of the fact that
cues (consequences, consistency of occurrence, cognitive theory is meant to be a comprehensive
and distinctiveness). The depressogenic attribu- theory of psychopathology. For each disorder,
tions lead to lowered self-esteem and to feelings the underlying generic model is applied, with
of hopelessness (which can be increased by additional components specific to each disorder
social factors, for example, lack of social (see later chapters on specific disorders). Newer
support) which are seen as sufficient to lead applications have not been tested in controlled
to hopelessness depression. Hopelessness de- outcome studies, but the empirical basis of
pression is characterized by retarded initiation cognitive therapy remains very much the
of voluntary responses (motivation symptom), tradition, with models tested in experimental
difficulty in seeing that similar or related studies, followed by case studies, and then by
outcomes can be controlled (cognitive symp- controlled trials.
tom), and sad affect (emotion symptom). For most disorders cognitive therapy remains
Although the specification of a subtype of short-term, except in the case of personality
depression as hopelessness depression in reac- disorders when therapy can extend to one or two
tion to negative situations has not led to specific years. Whereas in short-term cognitive therapy,
methods of treatment, the theory helps to give a weekly one-hour sessions are the norm, in
cognitive rationale for the well established personality disorders therapy sessions are often
finding of the role of life events in depression more infrequent, allowing the patient more time
(Brown & Harris, 1978). It also pinpoints the for homework assignments and more time to get
thinking style which may be of particular over the high levels of emotion which may be
importance in situational depression, and which stirred up during therapy. Typically, short-term
should, therefore, be targeted in cognitive therapy may last 10±20 sessions, although in
therapy. some cases (especially in panic disorder) fewer
sessions may suffice. Sessions are structured by
the use of an agenda which is set collaboratively
6.03.3 APPLICATION OF COGNITIVE by the patient and the therapist. This ensures the
THERAPY active participation of the patient and the
6.03.3.1 General Principles of Cognitive appropriate use of time. Generally, a session
Therapy agenda will include a review of previous
assigned homework; setting up one or two
There are several textbooks which describe relevant areas for discussion, these being often
cognitive therapy methods in detail for various related to previous homework; session feedback
psychiatric disorders: for depression (Beck et al., and deciding on appropriate homework for the
1979; Blackburn & Davidson, 1995; Williams, coming week. Throughout therapy, the thera-
1992); for anxiety (Beck, Emery, & Greenberg, pist must ensure that the process is collabora-
1985; Blackburn & Davidson, 1995); for tive, by giving and asking for feedback, by
personality disorders (Beck, Freeman et al., rehearsing, and by questioning. The therapist
1990; Layden, Newman, Freeman, & Morse, remains active and directive, but never pre-
1993; Linehan, 1993; Young, 1990); for groups scriptive. The style is gentle and questioning,
of disorders (Beck, 1995; Blackburn, Twaddle guiding the patient to elucidate their emotions
et al., 1996; Dobson, 1995; Hawton, Salkovskis, and thoughts, to evaluate them, and to arrive at
Kirk, & Clark, 1989; Padesky & Greenberger, alternative interpretations and solutions. This
1995); for psychosis (Birchwood & Tarrier, style of questioning has been described as
1994; Fowler, Garrety, & Kuiper, 1995; King- socratic questioning (Overholser, 1993a,
don & Turkington, 1994); for substance abuse 1993b). Questions are used for gathering
information, for discovering new perspectives, leads to an agreed list of problems which can be
for finding commonalities between situations, prioritized and targeted for therapy. An
patterns of thinking and emotions (synthesis), example of assessment is given in Figure 5.
and for achieving change. Overholser (1993a) Figure 5 indicates that although a detailed
differentiates between seven types of socratic conceptualization, as shown in Figure 2, cannot
questions: (i) memory questions (When did the be made at the assessment stage of therapy,
problem first begin? When did it last happen? nonetheless the therapist may already have
What did you do when it happened?); (ii) some clues about the basic assumptions and the
translation questions (What does it mean to core schemata of the patient derived from the
you? How can we make sense of this?); (iii) themes of the negative automatic thoughts and
interpretation questions (How are these situa- from the pattern of hypothesized predisposing
tions similar? Do your problems at work seem factors from early childhood experiences. In the
similar in any way to your problems at home?); example, a basic assumption may be ªIf people
(iv) application questions (What have you tried do not treat me properly, this means I am
in order to solve this problem? How will you go worthlessº and a core schema may be ªI am
about making these changes?); (v) analysis worthless.º Through questioning (e.g., What do
questions (What evidence do you have for this? you think is the most pressing problem for us to
How could you tell if you are right or wrong?); work on? What would help you most at the
(vi) synthesis questions (In what other ways moment?), problems are prioritized to bring
could you look at this situation? What does all about effective change quickly. This is a two-
this say to you? What does it mean to you to be a way process, so that the therapist and the
mother?); and (vii) evaluation questions (What patient reach conclusions collaboratively about
does it mean to you to be a success? How do you what priorities suggest themselves. In the case
rate yourself as a person?). described in Figure 5, the suicidal ideas and
Another general characteristic of cognitive wishes of the patient would take priority and it is
therapy is openness, that is, the therapist is usual to work then at a symptom level, using
explicit about the model of therapy, about the behavioral methods of treatment to increase
rationale for the procedures which are used, activity, in particular pleasurable activities.
about the formulation of problems, about their However, concurrently, during the therapy
own reaction in the therapeutic relationship, sessions, the therapist would start socializing
and about the rationale for homework assign- the patient into cognitive methods of treatment
ments. Feedback is elicited not only regarding to increase awareness of automatic thoughts,
the content of therapy, but also about the and to begin to evaluate these thoughts. An
patient's reaction to the therapist. This explicit initial conceptualization can then follow at
and open style not only fosters collaboration, about the fifth or sixth session of therapy, which
the model being of two scientists working is shared with the patient.
together to solve problems, but also ensures Conceptualization is an aspect of cognitive
that therapist and patient share a common therapy which is more emphasized now than it
understanding of what is going on in therapy. It used to be in the early days of cognitive therapy
is particularly important at the onset of therapy (Blackburn et al., 1996; Persons, 1989; see
to explain the model of therapy by sharing the Chapter 6.02, this volume for a detailed
generic model of cognitive therapy with the discussion). An example of a conceptualization
patient, using the diagram shown in Figure 4, was given in Figure 2 above. The cognitive
with real examples from the information conceptualization of cases will vary from
gathered in the first assessment. disorder to disorder and is done within the
Therapy is problem oriented: therapist and specific cognitive theory framework of that
patient engage in a functional analysis of disorder. For example, a conceptualization of a
problems in the assessment stage, so that case of panic disorder is given in Figure 6 to
therapy remains focused. The functional ana- highlight the difference from the case of
lysis includes symptoms (panic attacks, mood, depression in Figure 2.
hopelessness, suicidal wishes or behaviors, As Persons (1989) points out, conceptualiza-
situational avoidance, etc.), problem situations tion plays a crucial role in cognitive therapy:
(work, marital relationship, interpersonal re- (i) It helps the therapist to choose an inter-
lationship, etc.), life condition (employment, vention strategy, for example, it might indicate
social support, social network, etc.), proximal that environmental changes are possible and
trigger situations (e.g., loss or threat situations), indicated or that the patient's view of themself
maintaining factors (current hassles and pro- as vulnerable and weak is more central than
blems, coping strategies), distal factors (short their avoidance behaviors.
developmental history), typical automatic (ii) It helps to choose the treatment modality,
thoughts, and typical behaviors. This analysis couple therapy instead of individual therapy.
Early Experiences
Predisposing factors Mary * Oldest child with four brothers.

forming psychological * Relied upon by mother to help in the house.
vulnerability * Brothers cannot do anything wrong. Mary is
chastised or blamed.
* Made to leave school at 16, although top of
her class.
Formation of Basic Assumptions

and Core Schemata
Predisposing factors to
the problem Critical Incident
Husband leaves her for a younger

woman.
Situational factors
Basic Assumptions and Core
No employment outside the
Schemata Activated
home.
Current hassles/problems
Hyperactive son, aged 10.
Daughter aged 14 acting Negative Automatic Thoughts
out because of lack of
attention.
I’m not worthwhile.
Social network I’m inferior to other people.
No confiding relationship. People take advantage of me.
Critical parents. My life is finished.
I will never be loved.
Problems areas.
Depressive Symptoms
Behavioral Motivational
Stops doing her homework. Loss of pleasure.
Cries a lot. Indecision.
Avoids people. Suicidal wishes.
Affective Physiological/Biological
Low mood. Sleep disturbance.
Hopeless. Loss of appetite.
Sympathetic symptoms.
Figure 5 Examples of a functional analysis of a problem at assessment (Mary, age 42).

Upbringing Issues Events

* poor, inconsistent, chaotic and * use of diazepam
violent parenting * withdrawal of diazepam
* poor parental support * preoccupation with health
* childhood anxiety * use of alcohol
* premature notions of responsibility * loss of career
* current work problems
* mother’s death and father’s dementia
Basic Beliefs
Unconditional: “I’m vulnerable; my hearth is defective.”
Conditional: “If I panic, I’ll lose control completely; if I get
so frightened, my heart will stop.”
Stimuli/Situation
visit to the bank manager to ask for loan
Perception of Threat
“Fear”
Safety Behaviors Bodily Sensations

* taking wife along * chocking
* holding on tightly to briefcase * palpitation
* sitting near to door * nausea
* continuously checking pulse at wrist * sweating
* avoiding eye contact with bank
manager
Catastrophic Thoughts
* “My hand is shaking, she’ll see there’s something wrong
with me.”
* “My heart is racing, I’m going to break down in her office.”
* “If she refuses my application I might panic – my heart
might stop . . . If I die how will my wife and kids cope.”
Figure 6 Conceptualization of a panic disorder case (reproduced by permission of Souvenir Press from
Cognitive therapy in action. A practitioner's case-book. Blackburn, Twaddle et al., 1996).
(iii) It guides the therapist in the choice of an pist or likely to be noncompliant in terms of
intervention point, for example, what changes attendance and homework assignments?
are likely to bring about the most gain and are (v) It helps to make sense of the patient's
likely to have the biggest impact on the relationship difficulties both in and out of
hypothesized basic assumptions and schemata. therapy and this guides the therapist's beha-
(iv) It helps the therapist to predict the viors.
patient's behavior, for example, is the patient (vi) It may help to understand why therapy is
likely to become over-dependent on the thera- not working. The formulation may be wrong
and the therapist needs to consider new in- (iv) Lack of pleasure. Scheduling of poten-
formation that might have transpired in the tially pleasurable activities and rating activities
course of therapy and revise the original for- for pleasure. The therapist needs to ensure that
mulation of the patient's problems. the patient is not showing an all or none
(vii) Because a good formulation should lead response, that is not rating activities as pleasur-
to appropriate strategies, methods of treatment, able or not pleasurable and not confusing
and intervention points, length of treatment can ratings of pleasure with ratings of achievement
be much reduced as time is used effectively and (v) Lack of concentration. Practice engaging
economically. in activities (e.g., reading) in small bursts which
are reinforcing, instead of persevering when
6.03.3.2 Treatment Methods concentration has gone or giving up altogether.
The therapist must watch out for the patient's
Treatment strategies in cognitive therapy are self-talk or automatic thoughts.
driven by the case conceptualization which is (vi) Low mood. Engaging in distracting and
itself firmly based in the cognitive theory of the pleasurable activities. Mental imagery of plea-
emotions, as described in the earlier part of this sant memories.
chapter. Different targets of therapy may (vii) Anxious mood. Distraction, relaxation
require a different balance of cognitive, beha- techniques. Distraction techniques may involve
vioral, and emotional therapeutic methods, focusing on an object and describing it in
which emphasizes that cognitive therapy is minute details; developing sensory awareness
not a series of techniques to be mastered and by concentration on visual, auditory, olfactory,
applied technically. It is a system of psychother- and bodily sensations; mental exercises, for
apy requiring a thorough understanding of the example, reading, watching a film, or doing
cognitive theory of the emotional disorders, the crosswords.
familiarity with the experimental literature on Relaxation is an important technique for
which it is based, and knowledge and experience patients who feel they have no control over how
of psychiatric syndromes in general. In addi- they feel. Several relaxation methods have been
tion, the competent cognitive therapist needs to described (Bernstein & Borkovec, 1973; Gold-
display the general qualities of a good psy- fried & Davison, 1976), however, the applied
chotherapist; namely, genuineness, warmth, relaxation method described by Ost (1987) has
empathy, and understanding. been shown to be particularly effective. It
involves eight stages which can be taught
sequentially or in subsets: giving a rationale
6.03.3.2.1 Behavioral methods
for relaxation training; recognizing the early
Behavioral methods of treatment typically signs of anxiety; progressive relaxation; relaxa-
are applied early on in therapy as they can often tion exercises without tensing the muscles first;
provide relief for distressing symptoms which cue-controlled relaxation, that is, inhaling and
may prevent therapy from progressing. It is also relaxing to the cue word relax; differential
perhaps easier for patients to master behavioral relaxation, that is, learning to relax while
techniques, while concurrently getting socia- engaged in everyday activities; rapid relaxation
lized in cognitive techniques. Behavioral tech- by using several cues in the patient's environ-
niques are not used in cognitive therapy without ment; and, finally, application training which
examining concomitant effects on cognitions involves applying the learnt relaxation in
and emotions. anxiety provoking situations.
Typical behavioral methods of treatment and (viii) Lack of motivation. Schedule activities
the problems for which they are suitable are and grade for mastery and pleasure. The under-
listed below: lying rationale here is that the main problem lies
(i) Inactivity. Scheduling of graded activities in starting an activity and that, once started,
with reasonable goals to approximate in the motivation increases through the desire to finish
long run the patient's normal routine. the task (Zeigarnik, 1927) and the unexpected
(ii) Indecivesiveness. Planning daily activities pleasure experienced, much as appetite may
and rescheduling activities for another day if the actually be stimulated by the act of eating,
original plan has not been adhered to because of although there might not have been much desire
unforeseen circumstances. For life decisions, a to eat at the outset.
more cognitive approach may be indicated (ix) Panic attacks. Respiratory control ex-
(illustrated in Table 1). ercises which reduce panic symptoms due to
(iii) Procrastination. Establishing detailed hyperventilation (Clark, 1989). The exercises
daily plans of activities to reduce decision consist in pacing breathing to 12 breaths per
making. Again, it is necessary to ensure that minute or eight breaths per minute by breathing
the plans are feasible and attainable. for two seconds ªinº and for two seconds ªoutº
(12 breaths/min) or three seconds ªinº and three great deal of socialization is, therefore, neces-
seconds ªoutº (eight breaths/min) sary to guide the patient early on in therapy. A
(x) Avoidance. Exposure to avoided situa- good way for the therapist to decide whether
tions, in a graded and repeated fashion, for they have accessed the right automatic thought
example, social, phobic, or agoraphobic situa- is to ask themself: ªIs this thought consistent
tions. with the emotion that is reported?º, ªIs this
(xi) Safety behaviors. These are behaviors thought consistent with the degree of emotion
that anxious patients engage in when anxiety or that is reported?º, and ªIf I had the same
panic feelings have already started, for example, thought, would I feel as bad?º
holding on to solid objects, sitting down, There are several methods to guide the
pressing their head, checking their pulse rate. therapist about how to access the patient's
These behaviors can be very subtle and need to automatic thoughts:
be elicited carefully or observed during a (a) Direct questions. ªWhat was going
behavioral test. They need to be eliminated through your mind when you felt panicky?º;
gradually as they maintain the patient's beliefs ªWhat went through your mind when your
that symptoms are dangerous. husband criticized your housework?º This is
(xii) Rituals. Deliberate exposure to pre- evidently the easiest method and it is surprising
viously avoided situations or feared stimuli how often this is enough to trigger the appro-
(including thoughts) and prevention of com- priate negative automatic thoughts. This ques-
pulsive rituals and neutralizing behaviors, in- tioning also serves as a model for the patient to
cluding neutralizing thoughts. tap into their automatic thoughts at the time of
(xiii) Problem situations. Rehearsal in role- strong emotions or of self-defeating behaviors.
plays, with the therapist, of coping techniques (b) If direct questions do not prove useful,
and strategies, for example, assertiveness train- the therapist poses a series of questions to guide
ing, negotiations with a spouse or at work, and the patient to access the automatic thoughts.
anger control. This approach has been labeled ªguided dis-
It is already evident from the list of behavior- coveryº or ªsocratic questioning.º It is the main
al methods described above that they are technique which cognitive therapists need to
applied within a general cognitive strategy to master. It demands good listening skills, an
help in identifying the cognitions which are understanding of the patient's style of thinking
related to the problems, to test the patient's and a formulation of the problems which acts as
predictions and to modify expectations about a guide or a map.
the self, the world, and the future. (c) Sometimes the patient describes situa-
tions or events which may have caused pro-
blems in a detached way, the way they may
6.03.3.2.2 Cognitive methods describe a film or a book or a road accident that
one might have witnessed. These are probably
(i) Identifying automatic thoughts
examples of propositional and not implica-
The main emphasis at the beginning of tional meaning, as described by Teasdale
therapy, even while applying behavioral meth- (1993). In such cases, the therapist can use
ods of treatment, is the patient's automatic mental imagery to help the patient relive the
thoughts, which are considered as the basic data actual situation as vividly as possible, with all
of cognitive therapy. The patient needs to the sensory input which might be involved. This
understand the nature of automatic thoughts method helps in triggering strong emotions and
and how they affect emotions and behaviors the accompanying automatic processing which
and this is done from the time of assessment, might have taken place.
through questioning, noting spontaneous re- (d) For interpersonal situations, role-plays
ports of examples of automatic thoughts, and serve the same purpose. Having elicited the
including them in the model of therapy which is details of what actually took place, the therapist
presented to the patient. Because the very nature reenacts the situation by playing the role of the
of automatic thoughts indicates that they are other person involved as realistically as possi-
habitual and involuntary, some patients have ble, using posture, tone, and volume of voice to
difficulty in getting access to their ªhotº trigger the emotions and, hence, the automatic
automatic thoughts for several reasons: they thoughts.
have been used to taking them for granted; or (e) Moments of strong emotions are, there-
they report a commentary about their auto- fore, of crucial importance to access automatic
matic thoughts (thoughts about thoughts) thoughts. If emotion is not shown or expressed
through excessive intellectualization; or they in therapy, the therapist tries to elicit emotions
feel embarrassed about their automatic through imagery or role plays. If it is present
thoughts; or they consider them as silly. A during the session, the therapist uses the
Table 1 A method for dealing with indecisiveness. A married woman, with two school age children, having recovered from a depressive illness, cannot decide about her future
plans.
Alternatives Pros Importance Cons Importance Balance
1. Go back to I enjoyed the job, because of its responsibility. 80 It was not a 9am-5pm job, so I never knew when I would
the same job I knew the job and could do it well. 80 get home and sometimes I had to take work home with
on a full-time If I got depressed again I could have time off, as the me. 100
basis employers were very understanding the last time. 100 The pressure might make me ill again. 100
It gave me a good income of my own and made me It was not fair on the children not to spend more time with
feel independent. 20 them. 100
S+280 S+300 S720
2. Go back to It would give me more time with the children. 100 I would no longer have the responsibility which I enjoyed. 80
the same job The part-time income would still make me feel It is a difficult job to do part-time. I might find myself
on a part- independent. 20 doing as much as before for less money. 80
time basis. It would be less pressure and I might feel better. 100
I would be able to move to full-time again when the
children grow up. 100
S+320 S7160 S+160
3. Look for It would involve regular hoursÐmore time at home. 100 Better the devil you know. A new job might turn out
another part- May be less interesting, but would get out of the inappropriate. 80
time job house nonetheless. 60 I get bored by routine jobs. 80
which is less My husband would be happier with this. 50 Less money. 20
demanding Less pressure would be better for my health. 100
S+310 S7180 S+130
4. Not go back A lot of free time to do things with the children. 100 I would miss having an interesting job outside the home. 100
to work at I could use the spare time at home to study a I would be bored. 50
all. language or something else. 30 I would be resentful. 50
I could spend more time on my hobbies: gardening, In nine years time, by the time children have grown up, I
cooking, going out. 20 will be older and it would be more difficult to get into
Both sets of parents and my husband would approve. 50 the job market. 20
May be better for my health. 100
S+300 S7220 S+80
Final decision: There are advantages and disadvantages for all alternatives, but going back to the same job on a part-time basis is preferable.
Source: Blackburn, 1993, pp. 94±97.

moment to help the patient access the auto- (c) What is the effect of thinking that on me,
matic thought. It is particularly important to be on others?
aware of emotions which may not appear to be (d) What thinking errors am I making?
related to the current subject of discussion: the (e) Am I jumping to conclusions? (arbitrary
patient may become fidgety or tense, blush or inference),
start crying and the therapist then asks ªwhatºs (f) Have I considered all aspects of the
going through your mind just now?º situation (selective abstraction),
(f) Behavioral tasks have already been de- (g) Am I using one instance to draw general
scribed in the previous section as an invaluable conclusions, when there is no basis to do this?
method to train the patient to become aware of (overgenalization),
their thoughts as they feel the negative emotions (h) Am I catastrophizing? (minimization and
aroused while encouraging in behavioral tests. maximization),
(g) At the beginning of therapy, patients can (i) Am I taking this personally when it may
increase their awareness of negative thoughts by have nothing to do with me? (personalization),
simply counting them, using some sort of (j) Am I thinking in black and white? (di-
counter which they keep with them at all times chotomous thinking),
or keeping a tally on an index card. (k) Am I applying arbitrary rules, ªshouldsº
(h) The classical method of increasing aware- and ªmustsº when, in fact, there are no such
ness of negative automatic thoughts is the use of rules?
Dysfunctional thoughts records (DTRs) where Table 2 gives a list of 20 questions which can
the patient records the situation (what was be given as a handout to patients to help them
going on) when they felt a strong negative evaluate their automatic thoughts.
emotion, what the emotion was and at what When the degree of belief in the original
intensity and what were the automatic thoughts automatic thought is put in question, alternative
and what was their degree of belief in their interpretations can be considered, and the
automatic thoughts. Only these three columns probability of these alternatives can be assessed.
are used at the beginning of therapy and they The alternative interpretation, after careful
should be used in the session for training, before collaborative evaluation, can sometimes be seen
being given as a homework assignment. Several clearly as more likely and more realistic, but
examples of DTRs have been given in cognitive even if this is not the case, when the alternatives
therapy textbooks (Blackburn & Davidson, are not more probable than the original
1995; Hawton et al., 1989). interpretation, it is beneficial to see that one
interpretationÐis not necessarily correct, so
that the degree of belief in the distressing
(ii) Evaluating automatic thoughts
interpretation becomes reduced.
In the therapy sessions and as homework In the process of revaluation, a negative event
assignments, the patient learns to evaluate their or outcome may be reattributed to external
automatic thoughts. This can probably be instead of internal, less global, and less stable
considered the core of cognitive therapy, causes (Abramson et al., 1978).
involving the acquisition of the necessary skills It is particularly important that the alter-
to distance oneself from one's automatic native interpretations or conclusions that are
processing of information and to treat the arrived at be owned by the patient, rather than
products of thoughts as interpretations of dictated by the therapist, as the degree of belief
reality, rather than reality itself. These skills in the alternatives will depend on that. Degree of
are of crucial importance as they are gener- belief in the alternatives are rated and the
alisable to the evaluation of others and to basic resultant emotions rated. Thus, it is not taken
assumptions and core beliefs as well. for granted that because alternatives have been
The evaluation of automatic thoughts is done considered, the patient would automatically
through careful questioning to guide the patient believe in them and feel better. The DTR, with
to consider various alternatives to their original, the five columns, Situation, Emotion, Auto-
automatic processing and to adopt more matic Thought, Alternative Response, and
functional alternatives that they can test and Outcome is used for that purpose. An example
come to believe in. The therapist's questioning is given in Table 3.
becomes a model for the patient to apply to their To consolidate the patient's revaluation of
thinking outside of therapy. their automatic thoughts and the degree of
Questioning may take the form of: belief in them, several methods can be used, for
(a) What is the evidence for this interpreta- example, rehearsal, role-plays, and behavioral
tion? tests. Rehearsal simply restates the same
(b) Are there alternative interpretations situation or equivalent situations and the typical
which may be more realistic? automatic thoughts and the patient is invited to
Table 2 Twenty questions to help challenge negative thinking.
Question Response
Am I confusing a thought with a fact? The fact that you believe something to be true does not necessarily
mean that it is. Would your thought be accepted as correct by
other people? Would it stand up in court, or be dismissed as
circumstantial? What objective evidence do you have to back it
up, and to contradict it?
Am I jumping to conclusions? This is the result of basing what you think on poor evidence. For
instance, depressed people often believe that others are thinking
critically about them. But none of us are mind-readers. How do
you know what someone else is thinking? You may be right, but
don't jump to conclusionsÐstick to what you know, and if you
don't know, see if you can find out.
What alternatives are there? Are you assuming your view of things is the only one possible?
How would you have looked at this situation before you got
depressed? How would another person look at it? How would you
look at it if someone else described it to you?
What is the effect of thinking the way I do? What do you want? What are your goals? Do you want to be
happy and get the most out of life? Is the way you are thinking
now helping you to achieve this? Or is it standing in the way of
what you want?
What are the advantages and Many distorted thought patterns do have some pay-offÐthat is
disadvantages of thinking this way? what keeps them going. But do the disadvantages outweigh the
advantages? If so, you can think out a new way of looking at
things which will give you the advantages, but avoid the
disadvantages of the old way.
Am I asking questions that have no Questions like ªHow can I undo the past?º ªWhy am I not
answer? different?º ªWhat is the meaning of life?º ªWhy does this always
happen to me?º ªWhy is life so unfair?º Brooding over questions
like these is a guaranteed way to depress yourself. If you can turn
them into answerable questions, so much the better. If not, don't
waste time on them.
Am I thinking in black-and-white, all-or- Nearly everything is relative. People, for instance, are not usually
nothing terms? all good or all bad. They are a mixture of the two. Are you
applying this kind of black-and-white thinking to yourself?
Am I using global words in my thinking? Watch out for words like always/never, everyone/no-one,
everything/nothing. The chances are that the situation is actually
less clear-cut than that. Mostly it's the case of sometimes, some
people, and some things.
Am I condemning myself as a total person Depressed people often take difficulties to mean that they have no
on the basis of a single event? value at all as a person. Are you making this kind of a blanket
judgement?
Am I concentrating on my weaknesses and When people become depressed, they often overlook problems
forgetting my strengths? they handled successfully in the past and resources which would
help them overcome current difficulties. Once they can change
their thinking, they are often amazed at their ability to deal with
problems. How have you coped with similar difficulties in the
past?
Table 2 (continued)
Question Response
Am I blaming myself for something which Depressed people, for instance blame themselves for being
is not really my fault? depressed. They put it down to lack of willpower, or weakness,
and criticise themselves for not ªpulling themselves together.º In
fact, scientists have been studying depression for many years and
they are still not certain what causes it. Depression is a difficult
problem to solve and blaming yourself for it will only make you
more depressed.
Am I taking something personally which When things go wrong, depressed people often believe that in
has little or nothing to do with me? some way this is directed at them personally, or caused by them.
In fact, it may have nothing to do with them.
Am I expecting myself to be perfect? It is simply not possible to get everything right all the time.
Depressed people often set unrealistically high standards for
themselves. Then they condemn themselves for making mistakes,
or acting in ways they would rather not have done. Accepting that
you can't be perfect does not mean you have to give up trying to
do things well. It means that you can learn from your difficulties
and mistakes, instead of being upset and paralysed by them.
Am I using a double standard? You may be expecting more of yourself than you would of
another person. How would you react to someone else in your
situation? Would you be so hard on them? You can afford to be as
kind to yourself as you would be to someone else. It won't lead to
collapse.
Am I paying attention only to the black Are you, for instance, focusing on everything that has gone wrong
side of things? during the day and forgetting or discounting things you have
enjoyed or achieved?
Am I overestimating the chances of Depressed people often believe that if things go at all wrong,
disaster? disaster is sure to follow. If the day starts badly, it can only get
worse. How likely is it that what you expect will really happen? Is
there really nothing you can do to change the course of events?
Am I exaggerating the importance of What difference does a particular event really make to your life?
events? What will you make of it in a week, a year, 10 years? Will anyone
else remember what you now see as a terrible thing to do? Will
you? If you do, will you feel the same way about it? Probably not.
Am I worrying about the way things ought Are you allowing events in the world at large to feed your
to be, instead of accepting and dealing depression? Telling yourself life is unjust and people awful? It is
with them as they are? sad that there is so much suffering in the world and you may
decide to do what you can to change things, but getting depressed
about it does nothing to help.
Am I assuming I can do nothing to change Pessimism about the chances of changing things is central to
my situation? depression. It makes you give up before you even start. You can't
know that there is no solution to your problems until you try. Is
the way you are thinking helping you to find answers, or is it
making you turn down possible solutions without even giving
them a go?
Am I predicting the future instead of The fact that you have acted in a certain way in the past does not
experimenting with it? mean to say that you have to do so in the future. If you predict the
future, instead of trying something different, you are cutting
yourself off from the chance of change. Change may be difficult,
but it is not impossible.
Table 3 Example of automatic thoughts and how to answer them.
Outcome
Emotion Automatic (re rate belief
(rate de- thoughts automatic
gree, (rate belief, Alternative responses thought and
Situation 0±100%) 0±100%) (rate belief, 0±100%) emotion)
Woke up Disturbed, What mess am I'm crystal ball gazing. It may not be a Automatic
and kept anxious, I going to mess. However, if it is less organized thought
thinking of low (70%) have to go to? than before, it will be the (10%)
office (70%) responsibility of the supervisor. I can Anxious
situation only do my work as well as I can and (20%)
let other people worry about their
work (100%)
Source: Blackburn, 1993, p. 66.
evaluate these thoughts along the lines of the of the patient's cognitive system which under-
preceding discussion. In role plays, the thera- lies the way information is processed and which
pist may reenact a typical distressful scenario is considered to represent psychological vul-
and elicit thoughts and emotions or the nerabilities. Therapy at that level is therefore
therapist may play devil's advocate and play considered to be preventative. However, the
back the patient's automatic thoughts which relative emphasis put on eliciting and modify-
they then have to modify using the skills which ing core structures may vary from disorder
have been practiced beforehand. This is a to disorder, being most central in the person-
particularly impactful method which usually ality disorders and in depression and general
triggers high emotional responses. Several anxiety and possibly less so in obsessive-
attempts using role reversals are usually compulsive, panic, health anxiety, and psycho-
necessary. Finally, behavioral tests of the new tic disorders.
interpretation can be devised collaboratively
to check whether the new interpretation is
indeed more probable. These may involve (iv) Determining basic assumptions and core
polling friends and relatives to check their schemata
opinions in reality rather than mind reading;
facing rather than avoiding a confrontational As therapy progresses, general themes in
or self-assertive situation to assess others' problem situations and in automatic thoughts
reactions; engaging in, say, panic provoking become evident, as are personal rules, and these
situations, making predictions, and reviewing are discussed with the patient within the
the evidence after the behavioral test and conceptualization of problems as shown in
drawing conclusions. Figures 2, 5, and 6.
When dealing with automatic thoughts, The therapist listens attentively for the
several caveats need to be drawn to the attention implicit meanings of the patient's statements
of the therapist: working on peripheral rather and makes them explicit, as usual in question
than key automatic thoughts; dealing with form, for example, ªDoes this mean that if
questions instead of the underlying thought people do not like you, you are no good?º;
which prompts the question; buying into the ªDoes this apply to everybody or only to some
patient's system instead of keeping to a people?º; and ªDoes this mean that you are a
questioning style; not engaging in a thorough failure?º
evaluation of the thoughts; and not engaging in It is interesting to note that often, quite early
consolidation methods. on in therapy, the patient may express an
automatic thought such as ªI am a failureº
which, in fact, is their core schema. At this stage,
the patient may be totally unaware that this is
(iii) Basic assumptions and core schemata
their general view of themself and the therapist
These have been described in previous may have only an inkling that it is the patient's
sections and are an integral part of the core schema. It is therefore advisable to treat the
information processing model of the emotional statement as an automatic thought at this stage,
disorders. It is considered that therapy would as the patient has not yet acquired the skills to
be incomplete without dealing with this aspect evaluate automatic thoughts and an overall
understanding of the common thread in all the tionnaires are also open to response biases, and,
problems has not yet been reached by the by definition, cannot capture individual mean-
patient and/or the therapist. ings and idiosyncratic terminology.
To bring out the common themes in the
automatic thoughts, the therapist can use (v) Modifying basic assumptions and core
several examples to extract the general implica- schemata
tions of the automatic thoughts. This method
has been labeled the ªdownward arrowº Methods for modifying core structures are
technique, where the automatic thoughts are very similar to those used for the evaluation of
accepted as possibly true and their ulterior automatic thoughts, using the same style of
catastrophic implications arrived at through socratic questioning and of behavioral tests.
questioning. An example is given in Table 4. They might be classified as cognitive, behavior-
It is to be noted in the example illustrated in al, emotional, and inerpersonal methods. A
Table 4 that the patient is not encouraged to summary is presented below.
evaluate automatic thoughts at this stage, but (a) Cognitive methods. These involve weighing
instead is guided to consider the meaning the advantages and disadvantages of thinking in
implicit in the automatic thoughts which causes certain ways, for example, ªI must do every-
distress. At the end of this exercise, the therapist thing perfectlyº (see Table 5); examining the
would help put the conclusion explicitly: ªIt evidence for and against core beliefs, such as, ªI
seems from this that you are saying that people am worthlessº; establishing continua of zero to
will not respect you if you do not do things 100 to rate personal qualities; evaluating the
perfectly? Is this right?º (basic assumption); validity of personal rules; contrasting the short-
ªYou also say that it would simply confirm the and long-term utility of personal rules; examin-
fact that you are worthless?º Other examples ing the validity of the conclusions drawn at the
are then used to construct a consistent time when the basic schemata were arrived at in
formulation which gives the patient an overall childhood; collecting evidence contrary to the
understanding. basic schema. Padesky (1990) describes the self-
It may be an aid to therapy to use standard schema as self-prejudice to explain to the
questionnaires to elicit basic assumptions and patient how the basic schema acts to filter
core schema, for example, the DAS (Weissman information, so that only negative confirming
& Beck, 1978) or Young's schema questionnaire information
(1990). However, questionnaires should never is accepted and processsed, while disconfirming
be used by themselves, as discovery of the information is either transformed into confirm-
underlying structure needs to be a joint ing information or ignored or disqualified.
endeavor between therapist and patient. Ques- Padesky (1994) describes in detail several cog-
Table 4 Example of ªdownward arrowº technique to arrive at basic assumptions and

core schemata.
Situation: This is Helen's first day at the office

Emotions: Depressed (60%), anxious (70%)
Automatic thoughts
Helen I'm really dumb. I should have organised myself better.
Therapist ; Supposing that were true, what would it mean about you?
Helen It means that I can never get things right or do things properly.
Therapist ; Supposing that were true, what would it mean about you?
Helen It would mean that people cannot trust me to do things perfectly.
Therapist ; Supposing that were true, what would it mean to you?
Helen It would mean that I am second rate, useless.
Therapist ; Supposing that were true, what would it mean?
Helen It would mean that nobody would respect me.
Therapist ; And if nobody respected you, what would it mean?
Helen It would mean what I've always knownÐthat I am worthless.
nitive change methods and methods for con- marital, or family therapy if indicated; but more
solidating the new schema (e.g., keeping a usually; the therapist uses the interpersonal
positive data log). relationship in the therapeutic situation to
(b) Behavioral methods. These invlove enga- develop ideas about problems in interpersonal
ging in activities which disconfirm the basic style which are then discussed openly, as is usual
belief (e.g., do a piece of work in less than the in cognitive therapy.
usual time and testing whether not attaining
perfection entails social or professional cata-
6.03.3.3 Developments
strophies); or stopping behaviors which main-
tain the belief (e.g., stop avoiding meeting The area of cognitive therapy which has
people). developed the most in the 1990s is the
(c) Emotional methods. These may involve methodology for evaluating and modifying
some procedures from Gestalt therapy, for schemata. These changes have evolved gradu-
example, role plays of key painful experiences ally through theoretical developments (e.g.,
of the past, when the therapist, appropriately Teasdale & Barnard, 1993) and through the
briefed by the patient, can play the role of a expansion of cognitive therapy to new areas of
punishing parent or of an unfair teacher, and psychopathology, in particular to the person-
the patient plays the role of the child, but with ality disorders (Beck et al., 1990; Layden et al.,
an adult understanding. These role plays are 1993; Linehan, 1993; Young, 1990). Similarly,
rehearsed in role reversals several times, usually through, the influence of the constructivist
bringing strong emotional responses. Other approach (Guidano & Liotti, 1983; Mahoney,
emotional methods may involve examining 1993) and because of the wider application of
key experiences of the past and using reattribu- cognitive therapy, more emphasis is probably
tion methods to decrease self-blame and guilt put on developmental and interpersonal issues
which might have been reinforced by critical in the formulation of cases. Another area of
parents in childhood. Figure 7 below describes development is the application of relapse
the conclusions reached after discussing a prevention methods at the end of treatment
patient's sense of responsibility for the unhap- (Wilson, 1992). The importance of this stage of
piness of her parents. therapy is reflected in the dedication of a whole
(d) Interpersonal methods. These involve group, chapter to this topic in this volume.
Table 5 Weighing the advantages and disadvantages of a dysfunctional basic assumption.
Basic assumptions: I must do everything perfectly, if not, people will not respect me and I am worthless.
Advantages of this belief Disadvantages of this belief
It makes me try hard to do well It increases my anxiety, so that my performance suffers.

It makes me produce good work and be It stops me from doing many of the things I would like to do,
successful. because I may not succeed.
When something goes well, I feel really It makes me very critical of myself, so that I cannot take pleasure
good. in what I do.
I cannot afford to let my mistakes be noticed by anyone, and
therefore I probably miss out on valuable constructive
comments.
When I get criticized, I become defensive and angry.
My successes are undermined, because any subsequent failure
wipes out their significance.
I become very intolerant of others. I find so many faults in others,
that I cannot be warm and friendly. I will end up without any
friends.
I can never think well of myself because it is impossible to get it
right all the time.
Because I get so upset by failures, I cannot use them as valuable
experiences to learn how to do things better next time.
Source: Blackburn, 1993, pp. 113±1140

Socioeconomic
Mother’s
conditions of Father’s
depressive
country alcoholism
personality
8% 7%
35%
Myself
3%
World War II
7%
Lack of Marrying against

employment parent’s wishes
facilities 25%
15%
Figure 7 Responsibility pie chart. ªI was responsible for my mother's unhappiness.º
6.03.4 PROCESS OF COGNITIVE characteristics that are changed by treatment

THERAPY and which precede change in the dependent
variable of interest (level of depression). In
A large number of controlled outcome contrast, moderators are the variables that
studies, reviewed by Blackburn, Twaddle et al. predict treatment outcome, for example thera-
(1996), attest to the efficacy of cognitive therapy pists' competence level and patients' character-
in depression (Blackburn, Bishop, Glen, Whal- istics (gender, age, diagnosis).
ley, & Christie, 1981; Elkin et al., 1989; Hollon
et al., 1992; Murphy, Simons, Wetzel, &
Lustman, 1984; Rush, Beck, Kovacs, & Hollon,
1977; Teasdale, Fennell, Hibbert, & Amies, 6.03.4.1 Mediators of Change in Cognitive
1984); in general anxiety disorders (Butler, Therapy
Fennell, Robson, & Gelder, 1991; Durham
et al., 1994; Durham & Turvey, 1987; Power Cognitive therapy aims to bring about
et al., 1990); in panic disorder (Barlow, Craske, improvement by changing the hypothesized
Cerney, & Klosko, 1989; Beck et al., 1992, 1994; cognitive components which maintain the
Clark et al., 1994) and to a lesser extent in disorder. Cognitive changes after treatment
obsessive-compulsive disorder (Emmelkamp & have been found to correlate with level of
Beens, 1991; Emmelkamp, Van der Helm, Van improvement (Blackburn & Bishop, 1983;
Zainten, & Ploghg, 1980; Van Oppen et al., DeRubeis et al., 1990; Rush, Beck, Kovacs,
1995). However, there is little understanding of Weissenburger, & Hollon, 1982; Seligman et al.,
what are the actual critical components of 1988). Garamoni, Reynolds, Thase, Frank, and
cognitive therapy in effecting change and most Fasiezka (1992) reported that the balance of
of the work to date is in depression. Relevant positive to negative cognitions and related affect
studies have been reviewed by Whisman (1993) changed to an optimal range in responders to
and by Robins and Hayes (1993). A summary of cognitive therapy, but not in nonrespondents.
the main findings is provided here. Research has Persons and Burns (1985; 1986) also found that
attempted to differentiate between mediators changes in negative-automatic thoughts within
and moderators of change in cognitive therapy. session were highly correlated with within-
Mediators are the mechanisms or the patients' session changes in mood. The covariation
Process of Cognitive Therapy 77
between change in cognition and change in compared effects on mood produced by 30

depression has been found in studies using self- minutes of exploration compared with 30
rating measures (Beck, Ward, Mendelson, minutes of active modification of depressive
Mock, & Erbaugh, 1961), as well as observer thoughts. They found, in a within-subjects
ratings of depression (Hamilton, 1960). design, that active modification led to a greater
However, the effect of cognitive therapy on reduction of self-rated depression.
cognitive mediational variables is not unique to When cognitive therapy has been broken
cognitive therapy, pharmacotherapy having the down into components to analyze the different
same effect (Simons et al., 1984). Blackburn and aspects of cognitive therapy, mixed results have
Bishop (1983) attributed the larger effect of been obtained. McNamara and Horan (1986)
cognitive therapy relative to pharmacotherapy found that cognitive procedures reduced de-
on views of self, the world, and the future to the pressive cognitions and improved social skills
larger effect on level of depression at the end of more than behavioral procedures. Jarrett and
treatment in patients treated with cognitive Nelson (1987) divided the cognitive therapy
therapy relative to patients treated with phar- package into three components: self-monitor-
macotherapy. Hollon, DeRubeis, and Evans ing, logical analyses, and hypothesis testing.
(1987) argued that covariation between change All subjects received each treatment component
in cognitive variables and change in depression in one of two sequences. The results indicated
is not sufficient to prove that change in cognitive that self-monitoring did not bring about a
variables plays a causal mediational role in the change in symptoms, but logical analysis and
recovery process with cognitive therapy. In hypothesis testing brought about a decrease
addition, there must be a primary effect, that is, in depressive symptoms and in negative auto-
cognitive change must precede change in matic thoughts, a better level of interpersonal
depression and experimental manipulation of relationships, and a greater frequency of
the degree of change in cognition must pleasant activities. The two active components,
correspond to the degree of change in depres- logical analysis and hypothesis testing, were
sion. Few studies have succeeded in demon- more effective in combination than singly.
strating the primary change in cognition. Rush, Jacobson et al. (1996) randomly allocated 150
Kovacs, Beck, Weissenburger, and Hollon outpatients with major depression to partial
(1981), using cross-lagged correlations, found cognitive therapy (behavioral component and
that during the first four of 11 weeks of modifying automatic thoughts) or to full
cognitive therapy, improvement in hopeless- cognitive therapy (behavioral component,
ness, in view of self, and in mood preceded modifying automatic thoughts, and modifying
changes in vegetative and motivational symp- core schemata). They found partial cognitive
toms of depression. No specific pattern of therapy as effective as full cognitive therapy at
change was found in patients treated with the end of treatment and at six months follow-
pharmacotherapy. DeRubeis et al. (1990) up. Both the behavioral component and the
reported that changes in cognitive variables automatic component were as effective as full
(attributional style, dysfunctional attitudes, and cognitive therapy in altering negative thinking
hopelessness) at midtreatment predicted overall and dysfunctional attributional style. These
improvement at the end of treatment with results are in contrast with McNamara and
cognitive therapy, but not with pharmacother- Horan's (1986) and Jarrett and Nelson's (1987)
apy. If this effect is replicated in future studies, findings, indicating that more work is required
these authors' conclusion, that cognitive con- in this area.
structs play a mediational role in cognitive The debate about what type or level of
therapy, but that this effect is not sufficient as it cognitive change actually is achieved in cogni-
was not found in pharmacotherapy which was tive therapy is unresolved. Persons (1993), in a
equally effective, will be an important one in the theoretical paper, considers whether cognitive
understanding of the mode of action of therapy changes the basic schemata which are
cognitive therapy and of medication. presumed vulnerability factors or only teaches
Experimentally, a number of studies have compensatory skills. The two models generate
indicated that the manipulation of cognitive different predictions regarding the timing of
content, using the Velten procedure (1968) of change (which would occur earlier in the schema
reading self-referent sad statements, induces sad change model) and the generalizability of what
mood (Coleman, 1975; Hale & Strickland, 1976; is learned in therapy (the compensatory skills
Teasdale & Fogarty, 1979). These studies have model providing more general skills which
been much criticized because of the experi- might provide more protection against future
mental bias introduced by the inherent demand episodes of illness). The two models are
characteristics of the task. Perhaps more empirically testable and answers may be
convincingly, Teasdale and Fennell (1982) provided in future studies.
6.03.4.2 Moderators of Change in Cognitive positive predictor (Jarrett, Eaves, Grannemann,

Therapy & Rush, 1991; Sotsky et al., 1991).
In terms of illness characteristics, several
The Cognitive Therapy Scale (CTS; Young & studies have shown that the endogenous
Beck, 1988) is a 13-item rating scale which subtype of depression responds as well to
evaluates several aspects of cognitive therapy, cognitive therapy as to antidepressant medica-
the therapeutic alliance, adherence to the tion (Blackburn et al., 1981; Imber et al., 1990;
procedures of cognitive therapy (including the Kovacs, Rush, Beck, & Hollon, 1981). Severity
structure and content of therapy), and compe- of depression was found to be a negative
tence or skill in application of the methods and predictor of response by Elkin et al. (1989), but
techniques. The CTS has been found to have other studies have failed to replicate this finding
adequate psychometric properties (Dobson, (Hollon et al., 1992; McLean & Taylor, 1992;
Shaw, & Vallis, 1985; Vallis, Shaw, & Dobson, Thase, Simon, Cahalance, McGreary, & Hard-
1986), but the relationship of ratings on the CTS en, 1991). Since cognitive therapy targets
and outcome has not been demonstrated. cognitive dysfunction, it might be hypothesized
The quality of the therapeutic relationship that cognitive therapy would be relatively more
has been found by some researchers to be effective than control treatments (e.g., pharma-
positively related to outcome (DeRubeis et al., cotherapy) for patients with higher levels of
1990; Persons & Burns, 1985). In contrast, cognitive dysfunction. In a review paper, Rude
Bercham (1989) found no relationship between and Rehm (1991) conclude that research
therapeutic alliance ratings during early ses- findings do not support this prediction.
sions of cognitive therapy and outcome in the In terms of personal characteristics, level of
treatment of depression. DeRubeis and Feeley intelligence has not been found to be related to
(1990) found that the ªfacilitativeº aspects of outcome (Haaga et al., 1991) and the presence of
cognitive therapy (empathy, warmth, and a concurrent Axis II disorder (personality
understanding) and a measure of the helping disorder) has been found to be related to more
alliance did not predict change in depression residual symptoms of depression at outcome
level after the sessions in which they were rated. and poorer social functioning (Shea et al., 1990).
However, ratings of the helping alliance made Simons, Lustman, Wetzel, and Murphy (1985)
during later sessions of therapy were related to examined a number of predictor variables in an
prior change in depression symptoms. outcome study of depression and found that a
Several studies have demonstrated that cognitive variable, learned resourcefulness, was
cognitive therapy can be discriminated reliably the only reliable predictor. High learned
from other psychotherapies, for example, resourcefulness (as measured by the Self-Con-
interpersonal psychotherapy (DeRubeis et al., trol Schedule; Rosenbaum, 1980) predicted
1990; DeRubeis, Hollon, Evans, & Bemis, 1982; better response to cognitive therapy and low
Hill, O'Grady, & Elkin, 1992), indicating that learned resourcefulness predicted better out-
the procedures of cognitive therapy are specific. come with pharmacotherapy. Learned resour-
Only one study, by DeRubeis and Feeley (1990), cefulness refers to a set of coping and problem-
has examined the relationship between adher- solving skills that facilitate the monitoring,
ence to different aspects of the treatment control, and change of dysfunctional or un-
protocol and outcome. These authors found pleasant events. However, the finding by
that ªconcreteº and ªsymptom-focusedº meth- Simons et al. (1985) has not been replicated
ods of cognitive therapy predicted outcome, (Beckham, 1989; Jarrett, Giles, Gullion, &
whereas ªabstractº discussions did not. Rush, 1991; Kavanagh & Wilson, 1989).
Level of competence has been reported to be The short preceding review of the process of
related to outcome (Beckham, 1990; Burns & action of cognitive therapy indicates that find-
Nolen-Hoeksema, 1992; Hollon, Shelton, & ings are limited as they relate primarily to
Davis, 1993), but contrary findings have been depression. Both mediating and moderating
reported in psychotherapy (Shapiro et al., variables remain relatively unclear or unrepli-
1994). The issue of level of competence of cated.
therapists is of evident importance for outcome
studies and for training courses.
Since therapy involves a diadic relationship, 6.03.5 EFFICACY
patient's characteristics may be of equal
importance as therapists' characteristics for The efficacy of cognitive therapy relative to
outcome. Sociodemographic variables have other treatment methods has been well demon-
usually been found not to be important in strated, as can be seen in the various chapters
determining response to cognitive therapy, of this volume relating to specific disorders.
except that married status appears to be a Of particular interest is the long-term or
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6.04
Family Therapy and Systemic
Approaches
ARLENE L. VETERE
University of Reading, UK
6.04.2 FAMILY SYSTEMS THEORY 86
6.04.3 FAMILY LIFE CYCLE THEORY 87
6.04.4 SOME MAJOR SCHOOLS OF FAMILY THERAPY AND SYSTEMIC PRACTICE 88
6.04.4.1 Structural Family Therapy 88
6.04.4.2 Milan Family Therapy 89
6.04.4.3 Range of Therapeutic Techniques 89
6.04.5 DEVELOPMENTS IN FAMILY THERAPY THEORY AND PRACTICE 90
6.04.5.1 Feminist-led Critiques 90
6.04.5.2 Constructivism and Social Constructionism 91
6.04.5.3 User-friendly Approaches 92
6.04.6 RAPPROCHEMENT WITH OTHER THEORETICAL APPROACHES 93
6.04.6.1 Psychodynamic Influences 93
6.04.6.2 Cognitive Behavior Therapy Influences 94
6.04.7 ASSESSMENT IN FAMILY THERAPY AND SYSTEMIC PRACTICE 95
6.04.8 THE PROCESS OF CHANGE IN FAMILY THERAPY 97
6.04.9 CLINICAL PRACTICE PATTERNS OF FAMILY THERAPISTS 99
6.04.10 FAMILY THERAPY AND SYSTEMIC PRACTICE OUTCOME RESEARCH 100
6.04.11 TRAINING AND SUPERVISION 101
6.04.12 SYSTEMIC CONSULTATION 102
6.04.13 CONCLUSION AND THE WAY FORWARD 103
6.04.1 INTRODUCTION functioning of individual members of the

familyº (p. 565) The term ªsystemic psychother-
Gurman, Kniskern, and Pinsof (1986) de- apyº is a broader definition that includes, in
fined family therapy as ªany psychotherapeutic addition, intervention in other groups and
endeavor that explicitly focuses on altering the organizations using systems ideas and keeping
interactions between or among family members; a relational focus, for example, networking
and seeks to improve the functioning of the (Dimmock & Dungworth, 1985) and systemic
family as a unit, or its subsystems, and/or the consultation (Boscolo & Bertrando, 1993).
85
86 Family Therapy and Systemic Approaches
Systemic psychotherapy recognizes the recent family as part of the kinship network, the
important developments in family therapy kinship network as part of a culture, and so on.
theory and practice, building on the earlier In this way, general system theory was
pioneering work of the family therapists. adapted to the study of complex organization
and interaction in family household groups and
kinship networks. A major contribution has
6.04.2 FAMILY SYSTEMS THEORY been in the study of system adaptability, the
balancing of the homeostatic tendency, and the
Family therapy developed during the 1950s capacity for transformation. The family system
and 1960s as practitioners experimented with is defined in terms of its structure; its structure is
involving family members in the treatment defined as the network of relationships amongst
process. Early observations, such as ªsee-sawº its component members; and its relationships
effects in marriage, where improvements in the are defined in terms of interactions that are
psychological well-being of one partner as a mediated by communication, information ex-
result of individual psychotherapy seemed to change, and the development and transmission
herald a worsening for the other partner's well- of meaning. Thus, the family system is said to
being; or ªstatus quoº effects where improve- function to develop networks of operations
ments in individually treated psychological suitable for coping with the varied and change-
symptoms were not sustained; or the inability able environmental inputs and internal stresses
of individual approaches to address relationship to which it is subject.
difficulties per se, led early family therapists to Family system theorists are concerned with
speculate as to the importance of the social and the description of family rules, identifying
relational context for the genesis and/or main- hierarchies of feedback and control. Feedback
tenance of individual symptomatology. Thus, or recursive processes are believed to be char-
the family system or kinship network was acteristic of social systems, such as family
successfully placed at the center of therapeutic groups, where family members' output is
thinking. However, the early practitioners recognized as input at some later stage. Thus,
found their practice had developed ahead of explanations of behavior embrace circular
their conceptual thinking. They turned to notions of causality. Boundaries are said to
general system theory (von Bertalanffy, 1968) determine system and subsystem membership in
for its potential for application to the study of family groups, with family rules operating to
family process and family therapy. define who belongs to the subsystem and their
Systems research is concerned with the roles and tasks within the subsystems. Bound-
concept of self-organized complexity in living aries are described as more or less open
systems, a central tenet of which was that a according to the degree of exchange with the
whole functions as a whole through the inter- system's environment.
dependence of its parts. General system theory General system theory provided a conceptual
attempted to explain how this obtained in the framework for early attempts to describe
widest variety of systems, spanning the social, complex, time-related interactional behavior
physical, and biological world. Thus, the theory amongst family members, for which psycholo-
attempted to classify systems according to the gical and sociological theories were not suited.
way the parts were interrelated, and to describe It focused attention on the role of each family
typical patterns of behavior for the different member in the maintenance of psychological
classes of systems as defined. symptoms and took account of the various
Within the model of organized complexity, social and cultural variables impinging on
there exists a hierarchy of levels of organization, family groups. The development of individual
for example, organelle, cell, tissue, organ, distress was seen within a contextual, social
organism, such that each level of organization matrix and the treatment process addressed
is more complex than the one below, with each both individual needs and the needs of other
level characterized by emergent properties that family members. For example, Prince and
do not exist at lower levels and as such are not Jacobson (1995) examined the hypothesis that
reducible to previous events. Our example of a the treatment for depression in married women
biological system is said to have emergent needed to address the interpersonal environ-
properties, such as reproduction, self-organiza- ment. They examined three recent studies which
tion, and self-reflective behavior. Systems are compared behavioral marital therapy for dis-
described as open if they exchange materials, tressed couples with individual cognitive ther-
energies, and information with their environ- apy where the women were diagnosed with
ment. Thus, open systems can be considered unipolar depression. They found that both
subsystems of higher order systems, for exam- therapeutic approaches were successful in
ple, the individual as a member of the family, the reducing depression at six and twelve month
Family Life Cycle Theory 87
follow-ups, but that the couples therapy was grandparents might have a similar or different
effective in reducing the marital distress. set of expectations to the parents about their
The application of general system theory to involvement in rearing their grandchild, or a
the study of the family has been critiqued young couple might experience some difficulty
extensively (Pam, 1993; Vetere, 1987). Difficul- in establishing what is their province of decision
ties include a lack of clear conceptual defini- making relative to that of their extended family.
tions, necessary for operational definitions, and Carter and McGoldrick (1989) delineate a
overlap between the description and the ex- typical set of stages in development as follows:
planation of family system behavior. The con- courting couples, couples without children,
ceptual and practical focus on relational childbearing families with children in the pre-
processes led to a perceived diminution of the school years, families with school-age children,
importance of individual emotional experiences families with adolescents at home, families with
and motivations, and the emphasis on circular adolescents beginning to evolve separate lives,
causality led to a perceived diffusion of res- families with adult children, and families in
ponsibility within family groups for unaccep- retirement. Family members are said to face
table behaviors, such as violence and abuse. It is different challenges at different phases of the life
debatable to what extent family therapy practi- cycle, with different expectations of self and
tioners took circular causality to mean that others according to external demands and
victims of violence played a part in the develop- maturational and social demands for change
ment of violent patterns of behavior for which and adaptation.
they were accountable or blamed, or used the The life cycle stage model has been critiqued
concept of circularity to understand how such as applying to Western, middle-class, nuclear
processes arose. The current position separates families with less relevance for different family
the issue of responsibility for violence from the forms, some ethnic groupings, poor families,
explanation of how violent behaviors occur. A and so on (Vetere & Gale, 1987). Certainly, if we
linear moral stance is taken with respect to the accept the concept that a family is made up of
responsibility of the perpetrator for the abuse, different individuals at different stages of
and then only working therapeutically, using growth, the concept of family is difficult to
explanations and notions of patterning and grasp within this model. However, as a model it
circularity, when the perpetrator has admitted should purport to show how transitions affect
responsibility and engaged in a nonviolence adaptation, which demands a longitudinal
contract (Bentovim & Davenport, 1992). perspective within research. The model, while
not easy to put to the test, has construct validity
and its implications for other theories of family
6.04.3 FAMILY LIFE CYCLE THEORY functioning is considerable.
Definition of the family presents considerable
It has been proposed that family groups pass difficulties for family researchers and therapists
through phases, whose characteristics are (Trost, 1990). Trost's survey of general public
determined by changes within family members, definitions of the family revealed little agree-
the impact of external events on family ment, for example, with opinion literally divided
members, and the influence of sociocultural over whether a heterosexual marital couple
norms and requirements (Carter & McGol- without children constituted a family or
drick, 1989). Thus, the family system is seen to whether a lone parent and child constituted a
move through time, expanding and contracting family. The criteria for definition of the family
its membership as individuals join and leave the used by respondents to the survey were legal
system. The family is usually a multigenera- ties, biological relatedness, common residence,
tional system at any time, so that each and psychological significance, another concept
generation can be influenced by previous and which is difficult to define. In addition these
later generations. Special challenges to the criteria were weighted differently by the re-
family's organization, membership, and belief spondents. Thus, family researchers and thera-
systems, which may be experienced as stressful, pists differentiate between definition of an
are said to arise at transitional points in family individual's family, where an individual's
development, such as the birth of children, or perceptions of family life are accorded promi-
young adults establishing their own house- nence, and definition of the family unit, which
holds, where there is a confluence of external is believed necessary for the understanding of
and internal demands for changes, understood the development of family groups over time,
and interpreted by family members within the family-wide difficulties, impact of traumatic
context of transgenerational influences, that is, effects on family processes, and so on. For many
the handing down of family cultural beliefs, purposes therapists and researchers use the
expectations, and practices. So, for example, family household as the defining criterion.
A fully comprehensive theory of family family therapy, such as structural (Minuchin &
functioning is not available (Burr, Hill, Nye, Fishman, 1981), strategic/problem solving (Ha-
& Reiss, 1979a, 1979b). Family therapy apley, 1976; de Shazer et al., 1986; Weakland,
proaches involve a range of schools and theories. Fisch, Watzlawick, & Bodin, 1974), Milan
The rationale for family therapy assumes that (Selvini-Palazolli, Boscolo, Cecchin, & Prata,
most individuals are born into and develop in the 1980a), transgenerational (Lieberman, 1979),
context of family groups. The family is seen as constructivist and social constructionist (An-
the cradle and web of emotional development dersen, 1987; Hoffman, 1993), and narrative
and the early source of our attitudes and beliefs (Freedman & Combs, 1996).
about ourselves, our relationships, our past,
present, and future circumstances. The family is
the origin of our basic patterns of social inter- 6.04.4.1 Structural Family Therapy
action and interpersonal adjustment. Thus, the
system that is seen to create and support patterns Structural family therapy (Minuchin, 1974;
of behavior may be the means of describing, Minuchin & Fishman, 1981) is a body of theory
assessing, and changing interpersonal behavior. and techniques that approaches individuals in
Family therapy is said to be indicated: their social contexts and conceptualizes family
(i) when a child or adolescent is the referred interactions as habitual and sequential. Struc-
person; ture refers to the family's organizational
(ii) when family members define the problem characteristics, the subsystems it contains, and
as a family issue, such as relationship and the rules which govern interactional patterns
communication difficulties; among family members. An aim of therapy is to
(iii) when relationship difficulties threaten alter organizational patterns, particularly where
the future of the couple relationship or the modes of communication among family mem-
adequate care of the children; bers are seen to be dysfunctional. When the
(iv) when the family has experienced recent structure of the family group is transformed, the
stress, such as death, serious illness or injury, positions of members in that group are altered
loss of employment, ªleaving homeº issues; accordingly. As a result, each individual's
(v) when psychological symptoms have sec- experiences change. Thus, individual change is
ondary gain effects; and predicated upon system change.
(vi) when family members become organized Structural theory has five principal features:
into ªhelpingº with the problem in such a way (i) The family is a system which operates
that the attempted solutions become proble- through transactional patterns, that is, repeated
matic themselves. transactions establish patterns of how, when,
Family therapy is contra-indicated: and to whom to relate, and these patterns
(i) by practical limitations, such as the un- underpin the system.
availability of key members or the unavailabil- (ii) The functions of the family system are
ity of an experienced therapist; carried out by bounded subsystems.
(ii) when family members are ªsentencedº to (iii) Such subsystems are made up of indivi-
therapy by the courts as an alternative to legal duals on a temporary or permanent basis, and
proceedings and motivation to participate in members can be part of one or more subsys-
therapy is highly ambivalent; tems, within which their roles will differ.
(iii) when a family presents ªtoo lateº; (iv) Subsystems are hierarchically organized
(iv) when mediation might be more appro- in a way which regulates power structure within
priate; and between subsystems.
(v) in circumstances of precarious emotional (v) Cohesiveness and adaptability are key
equilibrium or emotional deprivation, when characteristics of the family.
family therapy is more appropriately considered Structural family therapy is described in three
part of a larger intervention programme, that stages: joining, middle therapy, and termina-
might include individual therapy, social sup- tion. Therapy is believed to be effective when the
ports, and practical aid. therapist forms a new system with the family.
The therapist relies heavily on techniques of
joining and accommodation, such as planned
6.04.4 SOME MAJOR SCHOOLS OF support for the existing family structure, track-
FAMILY THERAPY AND ing the process and content of family members'
SYSTEMIC PRACTICE communication, and accommodating to the
range and style of family affect. Middle therapy
The family systems tradition and the asso- interventions confront and challenge family
ciated discipline of family psychology have members at the three levels of symptomatic
given rise to a number of different schools of behavior, family structure, and family members'
Some Major Schools of Family Therapy and Systemic Practice 89
beliefs, in the attempt to create therapeutic events, relationships, beliefs, and the connec-
change. Interventions can include the enact- tions between them, illustrating Bateson's ideas
ment and re-enactment of interactional pat- about difference, information, and circularity.
terns, the development of negotiation and For example, different family members might
problem-solving skills, reinforcing parental be asked about their attitudes to a particular
authority, reframing interpersonal dilemmas, event, allowing the therapist to focus on
creating opportunities for empathic apprecia- difference without being too confrontational,
tion of others' perspectives and needs, providing exploring differences in meaning afforded to the
support for change, and negotiating tasks same event. Triadic questioning, asking one
within and between sessions. The therapy person for their view of the relationship between
contract is terminated when the family members two other family members, often produces
have rehearsed their ability to solve new changes in relationships as well as providing
problems and have had the opportunity to information for the therapists. Family members
solve earlier ones. learn to think in circular fashion and to become
observers of family process in a way that allows
different views to be enlightening and helpful.
6.04.4.2 Milan Family Therapy Neutrality refers to the therapist's attempts to
be even-handed in the session, allied to all
Milan family therapy approaches the family without getting involved in family coalitions
as a history-containing system with entrenched or alliances. It does not mean that the therapist
meanings (Selvini-Palazolli et al., 1980a). It is is indifferent or ethically neutral, especially
based on Bateson's (1972) circular epistemol- when working with abuse and violence in
ogy and focuses on information and difference. families. The therapist is more concerned with
The Milan family therapist searches for understanding the meanings in the system than
differencesÐin behavior, in relationships and with attempts to change the system. This is
in the way family members perceive and construe believed to be the process through which change
eventsÐand connections and links between occurs, that is, by not intervening to direct
ideas, behaviors, relationships and events. The family members, the therapist encourages the
approach assumes that these connections hold family members' ability to generate their own
the system in balance. solutions.
Milan family therapy has been described as Positive connotation is a form of reframing,
ªlong brief therapyº (Tomm, 1984) with whereby symptomatic behavior is seen as
sessions usually held monthly over a one-year positive or helpful because it keeps the system
period. The therapists work as a team, with two in balance and furthers family cohesiveness.
therapists usually interviewing the family and Thus, the intention behind symptomatic beha-
observed by two colleagues from behind the vior is seen in a good light, preparing the family
one-way screen. The session format often for a paradoxical injunction around the need
consists of an interview, followed by a break for family cohesion apparently to require the
when the two interviewing therapists retire presence of symptomatic behavior. Family
behind the one-way screen to consult with their rituals often mark and facilitate developmental
colleagues, and finishing with the delivery of a transitions in family life. They may be devel-
message to the family. The Milan interviewing oped as part of therapy to help clarify family
techniques consist of hypothesizing, circular dilemmas and promote new ways of doing
questioning, neutrality, positive connotation, things which may help family members change
and the use of rituals. Hypothesizing refers to their views and attitudes and see different
the presession formulation when the team options for behavior.
hypothesizes about what might be maintaining
the family problems. Hypothesizing helps
organize incoming information during the 6.04.4.3 Range of Therapeutic Techniques
family session, and is constructed continuously
as a result of feedback received from the family All family therapists use a range of ther-
to the questioning developed from the original apeutic techniques, which vary somewhat
hypotheses. Circularity throughout the system according to school, such as problem-solving
is stressed; problems and events are depicted as techniques, solution-focused techniques, direc-
interpersonal, such that a problem can be seen tive techniques (e.g., enactment, restructuring
as an event between two people. boundaries), neutral techniques (e.g., empha-
The use of circular questioning in the family sizing patterns in relationships), cognitive
session reflects and is guided by systemic intervention (e.g., reframing of relationships),
hypothesizing. Every question explores differ- between-session activity (e.g., tasks, rituals),
ences in family members' perceptions about narrative and restorying techniques.
The hallmark of the family systems ap- the concept of power and gender-based access to
proaches has been the development of methods sources of power (Hare-Mustin, 1986; Goldner,
of live supervision and consultation (Campbell, 1985, 1988). The sociological structural-func-
Draper, & Huffington, 1989), such as the use of tional theories of Parsons, which posited that
video and live observation teams located behind men held instrumental roles in family life and
one-way screens (Madanes, 1984; Whiffen & women held expressive roles, no longer went
Byng-Hall, 1982), in-room supervision (King- unchallenged. Thus, family therapy was seen as
ston & Smith, 1983), reflecting teams and a political process, in that it dealt with the
reflective practice (Andersen, 1987), and so on. allocation and distribution of power among
family members, the therapist and family
members, and so on.
Some significant contributions from feminist
6.04.5 DEVELOPMENTS IN FAMILY theorizing which influenced the development of
THERAPY THEORY AND family therapy thinking and practice included:
PRACTICE (i) recognition that men and women have
different experiences of self, of others, and of
Contemporary systemic thinking and practice life;
represents a knitting together of different (ii) recognition that men's experiences had
theoretical positions and concepts, such as: been more widely articulated than women's,
positive and negative feedback processes (re- which was underrepresented;
cursiveness); hierarchy of system levels; bound- (iii) recognition that women do not have
aries (open and closed); pattern in relationships equality of opportunity, despite recent legisla-
and meaning; family life cycle; communication tion in both the UK and USA (Central Statis-
theory; stability and change processes; sympto- tical Office, 1990);
matic and system change; the position of the (iv) placing the family in a historical context
observer in the system; feminist critiques of and challenging accepted views of the family;
gender, power, and inequality; narrative ap- and
proaches; and solution focused approaches. (v) calling for a re-examination of family life,
Increased emphasis on the conceptual integra- such as redistributing household and ªmother-
tion of different family therapy approaches ingº responsibilities, validating nontraditional
(Burnham, 1992; Liddle, 1991a), the fit between sexual and living arrangements, campaigning
therapist style and preferred models, and the for reproductive rights, and calling for an end to
needs of the family members and collaboration women's economic dependence on men.
in the therapy endeavor (Hoffman, 1993) can be Such theorizing highlighted how slow family
traced to recent theoretical developments in the therapists had been to identify the links between
field. For example, Goldner, Penn, Sheinberg, social inequalities and psychological distress.
and Walker (1990) describe the integration of Williams and Watson (1987) have argued that
social learning, psychodynamic, sociopolitical, the issue of asserting authority and power and
and systemic ideas in their therapeutic work having it acknowledged and respected is
with male violence in couple relationships. particularly problematic for women in a variety
Current systemic thinking and practices have of situations. In addition to the relative lack of
been strongly influenced by the feminist-led experience with leadership roles and the overt
critiques of power and inequality in family life use of power in public life and social institu-
(Perelberg & Miller, 1990), the postmodern tions, most women are reared in a multitude of
developments of constructivism and social nonverbal behaviors that communicate submis-
constructionism, and the emergence of user- sion and indecision. They suggest that men and
friendly approaches to family therapy (Reimers women traditionally have had differential access
& Treacher, 1995). to types of interpersonal power, and these
means of access are determined largely by sex-
6.04.5.1 Feminist-led Critiques role stereotypes and expectations. Women are
said to influence others more indirectly and to
The feminist-led critiques of family systems rely on their own personal resources including
theory and practice heralded extensive rethink- attractiveness, kindness, empathy, warmth, and
ing and revision of the assumptions and models close interpersonal relationships for the exercise
of working with families. Generation had long of referent power. Men are said to utilize more
been recognized in the field as an important direct means of influence, relying on a different
organizing feature of family life. Feminist set of resources, such as strength, skill, and
family therapists pointed out the dimension of competence and tend to be more indifferent to
gender as another organizing feature of family the interpersonal/intimate dimension for the
life and proceeded to analyze and deconstruct exercise of instrumental/expert power.
Developments in Family Therapy Theory and Practice 91
The feminist critiques of differential gender- Recently, there has been a shift from a
based access to power, and the new focus on woman-centred focus to gender-sensitive family
gender as a once hidden dimension of family therapy to an incorporation of analyses of male
life, had enormous implications for the practice psychological experience (Frosch, 1992; Mason
of family therapy. A gender-sensitive approach & Mason, 1990). The debate on how to engage
to family therapy developed, not as a set of men/fathers in the therapy process has been
specific skills or techniques, but as a process informed by research which seems to indicate
between therapist and family members which that men are less likely to seek help with
provided an opportunity for all family members emotional concerns than women (Verbrugge,
to negotiate both their individual and system 1985) and that when they do seek help, their
needs. Thus family therapists strived to be more problems are at a more serious stage of
aware of their own values regarding gender, as development (O'Brien, 1990). The risk of men
they are expressed in training, therapy and not being engaged is heightened: (i) if family
supervision; and began looking at the extent to therapy is seen to take place in ªwomen's timeº
which our ideas about differences between men and in a ªwoman's world,º so to speak; (ii) if men
and women are based on sexist stereotypes are slower on the whole than women to perceive
(Wheeler, Avis, Miller, & Chaney, 1989). indicators of relationship difficulties, and (iii) if
Family therapists are curious about the ways expressive differences between men and women
in which gender roles and stereotyping affect leave them believing that fathers get involved in
each individual in the family, the relationships therapy only when family distress is very high.
between family members, the relationships The greater difficulty in engaging men in the
between family members and other social therapy process leaves women shouldering the
institutions, and relationships between family burden of the responsibility for change, with
members and the therapist (Gregory & Leslie, fathers, albeit inadvertently, made peripheral.
1996). They ask questions that make explicit the Issues of culture and race have also been
issues, expectations, decisions, and behaviors critically examined in the practice of systemic
that demonstrate the degree to which equality of family therapists (Lau, 1987). Similar distinc-
opportunity and reciprocity exist between men tions have been drawn between cultural aware-
and women in the family. Using analyses of ness and culturally sensitive practices and the
interpersonal power, family therapists formu- role of training in promoting sensitive practice
late questions about how the presence or (Hardy & Laszloffy, 1995). Reflexivity in the
withdrawal of different sources of power affect training process has led to examination of how
everyday processes, such as decision making, therapists' cultural identities (which includes
negotiation, and conflict resolution. Family consideration of ethnicity, gender, social class,
therapists can use positive reframing and age, and so on) influence their understanding
relabeling to shift the conceptual and emotional and acceptance of those who are both culturally
perspective on an individual or a relationship. similar and dissimilar. Falicov (1988) suggests
For example, what may have been seen as that one way to help family therapists in training
personal inadequacy may be reinterpreted as to think culturally is for them to interview a
socially prescribed, by exploring with men and nonclinic family of a distinct ethnic or socio-
women what they have been taught about their economic group. To date, the literature consists
own gender roles and each other's, such as of theoretical critiques with clinical case
passivity as a model for female behavior or descriptions of culturally sensitive practice.
emotional impassivity as a model for male
behavior. Gender-sensitive family therapists
can facilitate consideration of a wider range 6.04.5.2 Constructivism and Social
of perspectives, behavior, and solutions that are Constructionism
less constrained by more traditional definitions
of roles and personal identity. For example, Constructivism and social constructionism
when discussing parental teamwork and shared have had a significant impact on contemporary
responsibilities, attention can be paid to the systemic thinking and practice (Hayward, 1996).
implications for both partners by checking that A postmodern perspective embraces issues of
the woman is willing to share parental respon- meaning and language, narrative, politics, and
sibility and has other ways of expressing her practices of power. Family therapy theory
competence, and that the man is willing to bear increasingly attends to the interpretive meaning-
the cost in the workplace of being more involved making dimension of experience and the multi-
in the family. Family therapists can use their ple contexts in which it occurs and evolves
ªgendered selvesº in therapy in a therapeutic (Cronen & Pearce, 1985). The usefulness of
manner, for example, by modeling alternatives systemic metaphors of family life has been well-
to traditional roles. documented; their further development
has been prompted by the interest in family ªreality,º and these shared views constitute an
members' beliefs and stories embedded in ªecology of ideas.º
language, with family members' ability to re- (iii) At any point in time, people can only
construe their worlds in accordance with values respond or take part in interactions that are
and aspirations seen as the central impetus to within or partially within their known repertory
change (White & Epston, 1990). This contrasts and experience.
with earlier notions of change in the field, where (iv) Sharing different versions of the same
change at the level of a relationship was seen to world or reality creates the conditions for
lead to change in an individual's felt experience. ªstuckº family systems to change, as family
Anderson and Goolishian (1988) argue that we members realize that they have more than one
are dialogical beings who evolve knowledge and perspective, option, or solution available to
meaning and attribute meaning to action them.
through conversation and other forms of social A fundamental tenet of this approach is that
interaction. These ideas suggest that we con- information needs to be shared rather than
struct stories or accounts about ourselves, withheld. This view is held in common with
others, and our relationships through social ªuser-friendlyº approaches to family therapy,
interaction. The major implication of these ideas discussed below.
is to suggest that the therapist's task is to help There are several different guidelines avail-
family members construct more useful stories able to the practicalities of reflecting team
about themselves and their relationships, for practice, although they all agree that discussion
example, by restorying the past and altering the should positively connote family members'
definition of the problem to change its meaning motivations where ethically feasible, and con-
and change its perceived effect on the present. tributors to the reflecting team discussion
The critical evaluation of systemic ideas and should build their comments on previous
practice, alongside the recognition of ªobserver- comments so a coherent account emerges during
created realityº has led to the development of the reflection. The theory and research under-
reflective practice and reflecting teams (Fried- pinning this approach is still in the early stages
man, 1995). Deriving from the work of of development. Jenkins (1996) has both
Andersen (1987) and colleagues, reflecting team critiqued the approach and begun research into
practices illustrate the notion of observing the theoretical assumptions, techniques, model
systems and the position of the observer in of change, indications and contra-indications,
the system. Reflecting team practice assumes using the Delphi technique.
that the therapist and family form a new system
during the process of therapy and that the
supervising reflecting team can observe and 6.04.5.3 User-friendly Approaches
reflect on the therapist/family system, family
dilemmas and problems, creating an enriched User-friendly approaches to family therapy
image of the family and fresh perspectives on (Reimers & Treacher, 1995) developed in the
their problems and potential solutions. Since UK in direct response to both a perceived
family members are invited to listen to the diminution in significance of individual sub-
conversation of the reflecting team one or two jectivity within some areas of family systems
times during each therapy session, family theorizing and a lack of research attention to the
members themselves assume the position of experiences of family members in therapy. A
the observer whilst listening, and when subse- recent book by Howe (1989) put forward some
quently invited to comment on the reflecting devastating criticisms of family therapy. Howe
team's conversation, we see an iterative process interviewed a small sample of families offered
of both therapist's and family members' views therapy by a team of social workers in social
and perspectives folding back on each other, services in the UK. The therapy was a mix of
much as in the way one might knead bread brief strategic and Milan approaches under-
dough, as pointed out by Lax (1989). taken by a single therapist, connected to a
Andersen first outlined the reflecting team in supervising team by closed circuit television and
his 1987 article. He suggested that the working an ear bug. The majority of family members
assumptions of the reflecting team included the interviewed found the hi-tech approach very
following: alienating and objected to ªtheirº therapist
(i) The observer generates many of the views apparently being controlled by some all-seeing
and distinctions we call ªreality,º with many yet unknown team.
possible interpretations present in those dis- Howe's book was helpful in that it mobilized
tinctions. a response to alienating practices, yet was
(ii) When people share their views, each flawed in that he failed to acknowledge the
person hears many different versions of this many developments in family systems theory
Rapprochement with Other Theoretical Approaches 93
and practice, not least of which is a longstanding events, beliefs, behaviors, and so on, as
debate on the ethics of family therapy thinking opposed to emphasizing the internal world of
(Walrond-Skinner & Watson, 1987) and the individuals, as in individual psychotherapeutic
necessity for therapy to be both ethically and models. Thus, the emphasis in family systems
politically defensible (Waldegrave, 1990). models of the creation of meaning through
User-friendly approaches recognize that interaction is different from a primary focus on
many family members find it very distressing the cognition of the individual. The under-
and problematic to come to therapy. Thus, it standing of psychological symptoms is rooted
places a premium on providing adequate in explanations of interactional process. For
information about therapy and pays attention example, individual development is conceptua-
to convening and engaging family members lized as a complex series of relationships which
(Treacher & Carpenter, 1983). The relationship extend beyond the individual, so a child's
of the therapeutic alliance to treatment effec- development is influenced by the child's
tiveness has not been researched in the field of relationship with the mother, the mother's
family systems therapy anywhere near as relationship with her partner, extended family
extensively as in the individual psychotherapies, relationships, prevailing economic and political
where the therapeutic alliance is held to be a conditions, and so on, in a rich contextual
common factor underlying much of effective interplay of different system levels. It is
helping. Research conducted by Bennun (1989) assumed that individual development and
found that fathers were more likely to engage in maturation are important and the systemic
therapy if they perceived the therapist to be approach focuses on how development is
competent, to show a positive liking for the understood and how these meanings affect
family and to have a problem-solving orienta- relationships. For example, a family systems
tion, whereas mothers preferred therapists to approach recognizes the importance of the
provide an opportunity for the airing of different meanings attached to a child's genetic
common concerns amongst the family mem- condition and how those meanings might
bers. Interestingly there seems to be a crossover influence relationships.
effect in middle therapy, where mothers pre-
ferred a problem-solving approach and fathers
had come to appreciate ªjust talking.º 6.04.6.1 Psychodynamic Influences
The effect of the therapist's race and gender
on the engagement process has received little Psychodynamic ideas have long informed
empirical attention in the family therapy family systems theory and practice as exempli-
literature, despite its prominence in family fied in the work of Ackerman (1958), Framo
therapy discourse over the 1990s. Preliminary (1982), and Skynner (1976). The psychody-
research by Gregory and Leslie (1996) with 63 namic view of personal motivation and sources
adult heterosexual couples suggests that black of anxiety and psychological discomfort has
females rate their initial sessions more nega- been generalized to the level of family group
tively than white females when seeing a white functioning. The psychodynamic systems ap-
therapist, and that black men had a more proach seeks to understand how intrapersonal
positive response than white men to the initial conflicts and motivations interlock and are
sessions, regardless of the race of the therapist. expressed at the interpersonal level, with a
These differences decreased over time. They specific focus on how such interlocking affects
found no significant effects for gender of the the development and expression of psycholo-
therapist, which is consistent with the very gical symptoms in family members. Proponents
limited research to date. Gregory and Leslie of this approach would be interested in how
speculate as to the role of perceived racial couples bring to their relationship separate
difference in engaging family members in psychological heritages rooted in their past
therapy and call for the identification of parent±child relationships and the extent to
procedures which enhance the probability of which past patterns of relating and introjection
family members staying in therapy. influence the current relationship. Applications
in practice would seek to understand the extent
to which such past attachments are problematic
6.04.6 RAPPROCHEMENT WITH OTHER for family members in their current relation-
THEORETICAL APPROACHES ships and, by using processes of insight, attempt
to bring about change in family members'
Family systems models and practice differ relationships. Goldenberg and Goldenberg
from individual psychotherapeutic approaches (1991) summarize the main differences between
because they focus primarily on relationships. psychodynamic approaches to family therapy
They emphasize relationships between people, and systemic approaches in the differing
emphasis on the role of past experiences and 6.04.6.2 Cognitive Behavior Therapy Influences
unconscious processes; the emphasis on insight-
vs. action-oriented techniques; the role of the Behavior therapists and cognitive behavior
therapist in making interpretations of indivi- therapists are interested increasingly in the
dual and family behavior patterns; and the utility of family systems ideas and practices.
major focus on the individual, in which the way Emmelkamp and Foa (1983) have written about
family members feel about each other is three sources of treatment failure, one of which
emphasized. is the neglect of, and/or the incomplete assess-
Wachtel and Wachtel (1986), writing from the ment of, the social contingencies and factors
perspective of individual psychodynamic psy- affecting clients' problems, in particular the
chotherapists, suggest a number of ways in extent to which a client's behavior is entrenched
which systemic ideas can inform the thinking in habitual and longstanding patterns of family
and practice of individual psychotherapists. interactions and expectations. The recognition
They recommend that individual therapists that some treatment failures might be the result
explore the systemic meaning of psychological of incomplete assessment of powerful social
symptoms by asking such questions as: contingencies has led some cognitive therapists
(i) What is the functional significance of the to address the question of what additional help
individual's symptom(s) for the family as a clients might need in order to benefit from their
whole? therapies. Bandura and Goldman (1995) de-
(ii) How would the family be stressed if the scribe how they developed a family systems and
individual were to change? cognitive behavioral analysis for use during
(iii) Does the symptom serve to restabilize a assessment to address the above question. They
family whose stability has been threatened? recognize that family systems models and
(iv) Is the symptom a result of an attempted cognitive behavioral models have different
solution to the problem that has in some sense theoretical underpinnings and do not attempt
ªbackfiredº and itself become the problem? any theoretical integration. Instead they point
(v) Is the symptomatic individual acting out to the areas of overlap and how the overlap can
someone else's distress? be useful in aspects such as the joint emphasis on
Such questions serve to contextualize our beliefs and rule systems governing behavior, the
understanding of the meaning of symptoms importance of attributions and expectations in
within the individual's significant emotional perceptions of self and others and the recogni-
relationships and puts the individual's problems tion of options for change, and the emphasis on
in a larger framework. problem-solving patterns and the significance of
Wachtel and Wachtel also recommend the interpersonal contingencies to the understand-
use of genograms (see Section 6.04.7) in ing of symptomatic behavior. Thus in therapy,
individual psychotherapy. Genograms are use- the focus on training in cognitive and behavioral
ful tools for exploring the transmission of skills to improve and enhance adaptive coping
multigenerational patterns and influences, and can involve the modification of environmental
provide a way of gathering information about contingencies that influence clients' problems.
an individual's implicit and explicit assump- This is an interesting and useful area of overlap,
tions, wishes, fears, and values. Wachtel and they would argue, because the family systems
Wachtel use the genogram like a projective test, approaches also focus on interrupting interac-
a map of the unconscious. In addition they tional sequences that are thought to influence
advocate the use of active interventions in symptomatic behavior. Some of these interac-
individual therapy as developed in family tional sequences are thought not to be reducible
therapy, for example, setting tasks (both to the level of individual behavior as they are
individual and systems-oriented); devising unique to systems functioning, examples are
rituals of celebration, mourning, and healing; communication processes, power and hierar-
using role play and role reversal interventions chy, patterns of disengagement and overinvol-
systemically; using systemic reframing and vement. Family systems ideas can thus help
paradoxical tasks that embody collaboration; cognitive behavior therapists expand their
and predicting relapses. Finally, they recom- functional analyses to include extended inter-
mend meeting ªthe cast of characters,º such as actional analyses underpinned by models of
adult siblings and partners, rather than enga- circular causality rather than the linear models
ging them in the therapeutic process itself, with of reinforcement contingencies. Systemic ana-
the following possible benefits: correcting the lyses and practices can be used to help under-
tendency to blame, sampling the individual's stand and overcome difficulties experienced by
interactional style, helping the system become clients during the therapeutic change process,
more receptive to individual change, and such as the broader costs associated with
helping to reconstruct the past. change, the client's involvement in familywide
Assessment in Family Therapy and Systemic Practice 95
dilemmas, and the influence of family process (iv) the context of family life, with specific
on the content and function of schemata. reference to sources of support and sources of
stress;
(v) both family and family members' life cycle
6.04.7 ASSESSMENT IN FAMILY stages and perceived expectations and tasks; and
THERAPY AND SYSTEMIC (vi) the meaning and significance of sympto-
PRACTICE matic behavior for family members.
The emphasis on areas of assessment will vary
The current and most widely used diagnostic according to the school of therapy. Common
system, the Diagnostic and statistical manual of pitfalls of assessment include ignoring the
mental disorders (4th ed., DSM-IV) (American developmental process, ignoring some family
Psychiatric Association, 1994), assesses and subsystem, and joining and supporting some
diagnoses individual psychopathology, and family members at the expense of others.
largely ignores the significance of interpersonal Gurman and Kniskern (1981) suggest that all
context to the development and maintenance of family assessments should make clear at what
psychological problems. The marital and family organizational and psychological level the
therapies are not covered by third party assessment is conducted, how soon therapy will
insurance payments in the UK and the USA, follow assessment, and the relationship between
despite the overwhelming evidence of their the different methods for collecting data and the
efficacy. Assessing systems of individuals de- means by which the data should be collated.
mands more complex methodology than in- Selvini-Palazolli, Boscolo, Cecchin, and Pra-
dividual assessment and differs in the following ta (1980b) paved the way for including the
ways. Assessment in family therapy is an referrer in the assessment process, partly to
ongoing process, occurring simultaneously with prevent the waste of family and staff time with
treatment. It is based on an understanding of inappropriate or ill-prepared referrals. Refer-
multiple levels of systems hierarchy and feed- rers are often invited to preliminary consulta-
back processes within and between levels. tion meetings with family members and the
Assessment guides intervention. It can be therapy team or wider network meetings to
conducted either as a clinical process through establish who in the system wants the referral
interviewing and observation or as formal and any differing views and expectations of the
psychometric procedure using both ªinsiderº referral. The importance of thinking of referrers
and ªoutsiderº reports. systemically as part of the process of convening,
Minuchin (1984) writes that for therapy to be engaging, and assessing families has tended to
effective and for assessment to take place, the lead to a decline in nonattendance rates
therapist needs to form a new system with the (Reimers & Treacher, 1995).
family: the therapist plus family system. In this, Lieberman (1995) and his colleagues at the
the therapist relies on techniques of accommo- Prudence Skynner Family Therapy Clinic have
dation and joining. Accommodation is the developed an assessment and observation form
adjustment of the therapist to the family system. that is used by both observing team members
Aspects of accommodation are: maintenance, or and the therapist to collate their views after the
planned support of the existing family structure; first family interview. They adapted the Current
tracking, following the content and process of State Family Assessment (Loader, Burck,
the family communication; and accommodating Kinston, & Bentovim, 1980) into five separate
to the family's style and range of affect. Joining areas of observation:
is the therapist's own method and style of (i) process:
helping to form the new therapist plus family (a) communication patterns, such as inter-
system, so that the therapist does not lose the ruptions, listening, speaking for self and others,
position of facilitator. contradictory verbal and nonverbal messages;
The areas for assessment in systemic work (b) family atmosphere, such as the predomi-
with families cover the following: nant mood, whether it is shared by all, what
(i) the family's structure of subsystems, roles makes it change;
and boundaries, preferred transactional pat- (c) family alliances, such as rigid vs. flexible
terns, and available alternatives; alliances, presence of conflict and problem
(ii) family members' strengths, flexibility, solving, scapegoating;
and capacity for change as revealed by re- (d) feelings, such as the range, intensity and
sponses to changing circumstances, past and expression of feelings, presence of empathy;
present; (e) family boundaries, such as rigid or
(iii) family members' perceptions of and diffuse generational boundaries, cross-genera-
sensitivity to each other's needs, behaviors, tional alliances, parental role responsibilities,
attitudes, and so on; differentiation, and connectedness;
(ii) family seating arrangements; interaction over a 10 minute period. The scale
(iii) content of the interview; evolved from general system theory and studies
(iv) formulation and themes; and of well-functioning vs. dysfunctional families.
(v) feedback and tasks given to the family. Competence is defined broadly as how well the
A popular atheoretical assessment tool used family performs its necessary tasks, such as
by family therapists is the genogram, derived providing support and nurturance, establishing
from the work of the transgenerational family effective generational boundaries and leader-
therapists (McGoldrick & Gerson, 1985). As ship, promoting developmental separation and
many families are made up of many people autonomy of offspring, negotiating conflict, and
experiencing a multitude of events across many communicating effectively.
generations, recording this information in a The Style scale is a nine-item observational
concise and coherent way can be difficult. The rating scale. The Style dimension represents
genogram provides a vehicle for recording elements of enmeshment and disengagement at
social, emotional, and demographic data across its extreme points, such as extremes in binding
the generations, such as births, deaths, mar- and expelling patterns; and affective patterns,
riages, divorces, life events, emotional connect- such as subdued conflict where anger is
edness, and so on. It provides a means of threatening vs. open conflicts and hostility.
exploring the meaning and impact of events Families at similar ªcompetenceº levels may
across the generations, engaging all family show different functional ªstylesº of relating.
members in the telling. Thus, the process of The model assumes that competence in small
constructing a genogram allows the therapist tasks is related to competence in larger domains
and team to contextualize such assessment of living. The Self-Report Family Inventory is a
questions as ªwhat is the current family 36-item self-report scale and measures the major
problem?,º ªwhat factors maintain the pro- elements of family competence and style, the
blem?,º ªwhy do family members come for cornerstones of the Beavers Model. The scales
therapy now?,º ªwhat are their expectations of have been developed during 30 years of research
therapy and the therapist?,º ªhow have they into normal family functioning. The internal
tried to solve the problem previously?º within consistency of the scales, their construct validity
an understanding of background data on the and inter-rater reliability have been extensively
characteristics of both the household family researched and demonstrate acceptable levels of
group and extended family network. reliability. Such rigorous attention to issues of
It has been noted by many beginning family reliability and validity requires considerable
therapists that constructing a genogram is a way investment in the training of raters. Most family
of putting family members at their ease in the therapists and supervising teams are unable to
early stages of therapy, not to mention helping invest such resources in training, so the more
to reduce the anxiety of the therapist. It is a formal psychometric scales are rarely used in
visual and active method that concentrates the day-to-day practice, mainly being used in
attention of all participants, and provides a research trials. Family therapists rely on clinical
rationale for negotiating change. The construc- interviewing and observation, teamwork,
tion of a genogram also has strong therapeutic knowledge and experience of family patterns
influence as it can be used to reframe behaviors, for the assessment and formulation of family
events, relationships, and time connections; to difficulties, sometimes supplementing their
make links across the generations and across assessment with more formal procedures.
emotional cut-offs; and to normalize some Termination of therapy will be discussed here
perceptions. It may facilitate alternate inter- as an assessment issue because the iterative and
pretations of a family's experience and point the interactive nature of assessment and formula-
way to new possibilities in the future. tion in part determines the decision to end
Other more formal, psychometric assessment therapy. Theorizing and empirical research on
methods are available, such as the Beavers ending therapy is under-represented in the
Systems Model scales (Beavers & Hampson, family therapy field compared to the other
1990). These include the Beavers Interactional psychotherapies (Treacher, 1989). Since family
Competence and Style scales and the Self-Report therapy was developed by and is often practiced
Family Inventory. The Competence and Style by clinicians trained in other modes of therapy,
scales are completed by observers, using video- notably individual therapies, there is a tendency
taped family behavior as the basis of their ratings in the family therapy literature to assume
and the Self-Report Inventory is completed by knowledge of both convening and engaging
all family members above the age of 12. The issues and termination issues in family therapy.
Competence scale is a 13-item structured Readiness for termination is assessed when
observational rating scale, with ratings derived family members resolve or learn to cope with the
from trained observers' evaluations of family presenting difficulties, when they demonstrate
The Process of Change in Family Therapy 97
increased independence and/or cooperation, processes from theoretical articles, technical

when they display more ªopenº styles of articles, and clinical workshops. This material
communication, when they report an increased tends on the whole to focus on what therapists
sense of security and show greater flexibility in should do, rather than considering what family
performing family roles. According to the members themselves need to do. The exception
orientation of the family therapist and team, is the work of Kuehl and colleagues, who used
they will typically review whether family ethnographic interviewing procedures in an
members' expectations of the therapy process iterative manner to elucidate accounts of inter-
have been met, summarize the treatment personal change from family members who had
process and enquire about helpful and unhelp- undertaken strategic/structural therapy for help
ful aspects of the therapy, predict and rehearse with adolescent drug misuse (Kuehl, Newfield,
future coping in similar situations, and offer a & Joanning, 1990).
follow-up meeting far enough ahead for the It is important to note when reviewing family
family members to have tested out their new- process studies, that family therapists are
found confidence. challenged by complex demands and intraper-
sonal and interpersonal tasks during the therapy
session that do not occur during individual
6.04.8 THE PROCESS OF CHANGE IN therapy. For example, the therapist may create
FAMILY THERAPY interpersonal alliances with family members
who may well be in conflict with one another,
The main change mechanisms in family manages the multiperson conversation in a
therapy are considered to be at the symptomatic collaborative and facilitative manner to prevent
level, the level of family structure, and the level it becoming destructive, uses family members as
of beliefs held individually and collectively. The ªcotherapists,º assesses and intervenes in live
different schools vary in their emphases. enactments of problematic family interactions
Structural therapy posits change in individual and problem-solving attempts, and so on.
experience as a result of change at the level of the Friedlander, Wildman, Heatherington, and
family's organizational structure. For example, Skowron (1994) reviewed family process re-
a child's experience of parenting is said to search, including naturalistic studies of conjoint
change if the two parents learn how to work as a therapy in which the focus of the study was
team rather than undermining each other's verbal behavior of the therapy participants
decisions. Strategic and brief therapies focus on during therapy or their self-reported percep-
symptomatic change, and use an understanding tions of actual interactions during therapy.
of interpersonal dilemmas and difficulties as Thirty-six studies, dating from 1963, met their
ineffective solutions to problems that are main- inclusion criteria. Following Greenberg (1986),
tained because people are unable to generate they organized their review hierarchically and
alternative solutions. Milan therapy uses inter- focused on three levels of in-session behavioral
vention questioning to identify and highlight processes: (i) speech acts during therapy, (ii)
connections between beliefs, behaviors, and important incidents or change episodes during
relationships, with change occurring as a result therapy, and (iii) the therapeutic relationship.
of the development of new perspectives within Their review builds on the previous review of
relationships. These changes are achieved using family process studies conducted by Gurman,
a range of techniques, described earlier in the Kniskern, and Pinsof (1986).
chapter. The following discussion will consider The bulk of family process research has been
how the family therapy process studies have conducted at the speech act level of analysis,
investigated the processes hypothesized to bring where all behaviors occurring during a specified
about change and actual change. segment of interaction are observed. Frequen-
Family therapy process studies investigate cies or proportions of these observed behaviors,
change mechanisms common to the various such as rates of participation, types of response,
types of family therapy. To date, most research and modes of expression are compared or
has focused on family therapy outcomes, otherwise used to predict successful therapy
demonstrating the efficacy of family therapy outcome. The following questions have been
for many different psychological disorders as addressed using speech act analyses: What
classified. The question of how interpersonal factors predict premature termination of family
change is facilitated during family therapy is of therapy? What are the common and distinctive
most interest to the practicing family therapist, features across different modalities of therapy?
who is concerned with effective interventions, What is the relationship between participants'
yet this is the area where there is a relative gender and therapy process? What interperso-
paucity of research. Thus family therapists tend nal changes take place during the course of
to seek information on interpersonal change therapy, and so on. For example, Alexander,
Barton, Schiavo, and Parsons (1976) found that ªsupport or facilitateº interventions, as coded.
the proportion of defensive to supportive speech Using a larger sample from the same child
acts was significantly higher in families who behavior management project, Patterson and
terminated their therapy prematurely. Shields, Chamberlain (1988) identified instances of
Sprenkle, and Constantine (1991) compared ªmother±father within-session conflictº and
families who ended therapy prematurely with using path analyses suggested that extraneous
those who completed therapy in agreement with forces, such as parental stressors, marital con-
the therapist. They found that families who flict, and depression, appear to increase the
ended therapy early were characterized by more within-session conflict among family members.
in-session disagreements and more attempts to This study is important in elucidating the role of
structure the therapist, compared to more factors outside therapy sessions that have a
family problem-solving conversations and more bearing on behavior in therapy. In addition they
therapist structuring in response to family found high correlations between in-session
disagreements in families who completed ther- conflict and antisocial behavior scores for the
apy. The results suggest that defensiveness children. Patterson and Chamberlain conclude
amongst family members may predict early ter- that therapists should plan interventions that
mination, although we do not have other in- help to reduce external parental and marital
formation about the families and their contexts, stressors outside the sessions. The Patterson
so that the correlations may be misleading. A studies rely on small samples but do provide
study by Dowling (1979) examined the con- some interesting support for family systems
sistency of therapist verbal behavior according ideas.
to their role, therapist versus cotherapist. She The third level of analysis in the family
found that therapists behaved similarly with process studies is the therapeutic relationship
different cotherapists and with different fa- itself. Family therapists have not researched the
milies, supporting the notion that therapists had ingredients believed to be important by indivi-
a consistent cotherapy style. dual therapists in establishing a therapeutic
Postner, Guttman, Sigal, Epstein, and Rakoff relationship, such as warmth, empathy, accep-
(1971) investigated family members' verbal tance, and unconditional regard. Instead they
behaviors as predictors of outcome. Interac- have attended to the more strategic and systemic
tional segments were analyzed at four points in aspects of the therapeutic relationship, such as
therapy for 11 families. Speech acts were coded engaging and joining the family, and the
into emergency, welfare, or neutral emotional development of therapeutic coalitions. Gurman
states. Outcomes were coded as good or bad by and Kniskern (1978) concluded that the family
three independent judges. Results from the good therapist's ability to establish a positive ther-
outcomes showed that family members tended apeutic relationship with family members was
to speak more to each other during the course of most predictive of successful outcome. Since
therapy, that welfare statements increased that time very few studies have been conducted
during the course of the therapy, and that sig- and only six met the inclusion criteria of the
nificant changes in emotional expression oc- Friedlander et al. review discussed here. Shapiro
curred between the second and sixth sessions. (1974) concluded that greater therapist emo-
Unfortunately the speech act studies reviewed tional responsiveness to family members, as
by Friedlander and her colleagues provide little measured by questionnaire, predicted client
accumulated knowledge towards answering continuance in therapy beyond the initial
how change occurs over time during successful assessment phase. Families who were not
therapy. Different investigators have used seen in such a positive light by their therapists
different coding systems within different theo- tended not to continue in therapy beyond
retical frameworks, thus the generalizability of assessment. These ratings are global with little
the findings is limited. psychometric support. Later research by Pinsof
There have been a few attempts to research and Catherall (1986), using a more robust
therapeutic episodes in the hope that by psychometric measure of therapeutic alliances,
identifying significant moments in therapy, explored the development of therapeutic alli-
interpersonal change processes will be more ances across family therapy sessions, and found
readily elucidated. An example is provided in that such alliances often develop variably rather
the work of Patterson and Forgatch (1985), who than uniformly. Their research showed a
identified and coded instances of maternal tendency for positive correlations between
ªnoncompliance.º They found that noncom- alliance ratings and therapist-rated outcomes,
pliance responses were more likely to follow with most family members rating their therapist
therapists' attempts to ªteach or confrontº positively, and interestingly, that alliances are
mothers, as coded, whereas a decrease in non- best understood as both multidimensional and
compliance was coded following therapists' occurring on multiple levels. Examples are:
Clinical Practice Patterns of Family Therapists 99
whole system alliances, subsystem alliances, and explored alongside observer ratings. Interper-
individual alliances. sonal process recall as developed by Elliott
The study by Kuehl et al. (1990), referred to (1984) in the context of exploring individual
earlier in this section, will be discussed here therapy process has promise for exploring
because it is an interesting exploration of family family members' perspectives during family
members' views of therapy and the change therapy. The bulk of the process studies have
process. Twelve families (37 individuals) who researched the more established styles and
had completed family therapy with successful schools of family therapy, with the newer
outcomes for adolescent substance misuse were constructivist approaches remaining to be
interviewed. Family members identified stages explored. But perhaps the real challenge to
in the therapy process, collectively described as family process research lies in developing
the introductory meeting, assessment, getting methods that both avoid isolating behavior
down to basics and generating suggestions, from its social context and isolating individual
putting suggestions into practice, sharing behaviors from the stream of behaviors.
successes with the counselor, and troubleshoot-
ing and follow-up. Satisfaction with the therapy
seemed to depend on family members' percep- 6.04.9 CLINICAL PRACTICE PATTERNS
tions of the therapist as caring and under- OF FAMILY THERAPISTS
standing and able to generate relevant
suggestions, whereas dissatisfaction was re- There is little published data on the clinical
ported if the therapist was thought to be on practice patterns of family therapists, whereas
ªtoo strict a program.º The flexible use of in both the UK and the USA there is a growing
theory was valued by family members. Where body of data on the practitioner demographics
parents reported that they considered their and clinical practice patterns of clinical psy-
marital problems to be contributing to their chologists, psychiatrists, and social workers
child's problem, there was a willingness to (VandenBos & Stapp, 1983). Because of the
explore this connection. Where parents believed increased interest in family therapy, its effec-
their own problems to be separate from those of tiveness as a mode of therapy (Pinsof & Wynne,
the adolescent, attempts by the therapist to 1995), and the expanding role of family
explore a possible connection was the point at therapists in larger health care teams, Simmons
which therapy was reported to ªstall.º and Doherty (1995) surveyed the clinical
Friedlander et al. (1994) conclude that most practice patterns of marital and family thera-
family therapy process studies are descriptive pists in Minnesota, USA. Marriage and family
and at the speech act level of therapeutic therapists are currently regulated in 31 states
process. Compared to the wealth of family through State and Federal legislation. In the
therapy outcome research, there are few process UK registration of family therapists is through
studies, but a few conclusions are possible. the United Kingdom Council for Psychother-
These include: individual symptoms as observed apy, and in Europe many countries require the
in therapy occur in the context of predictable registration of family therapists as specialist
interpersonal events; there are more common- psychotherapists.
alities across family therapy approaches than Simmons and Doherty surveyed American
differences, with therapists behaving consis- Association for Marriage and Family Therapy
tently across family work, central in their (AAMFT) members from Minnesota (N = 76)
position with families and skillful in indirect for educational qualifications, demographic
communications; changes over time in the characteristics, and practice-related issues. In
course of therapy with positive outcomes as addition they sought data on 199 treatment
affective, cognitive, and behavioral, observed cases involving a total of 351 clients, which they
both interpersonally and intrapersonally; affec- claim as a first in the field of marital and family
tive changes among family members appear to therapy.
be crucial to effective therapy; family members' Their major findings were that: (i) short-term
responses to their therapists and their thera- therapy is practiced, with an average case
pists' responsiveness to them appear to be involving 11 sessions over a four-month period;
important; and finally, family members' moti- (ii) therapy with families (average of eight
vations to engage in therapeutic activities are sessions) and couples (average of 10 sessions) is
predictive of good outcome. More research is briefer than that with individuals (14 sessions
needed to address how family members them- average); and (iii) a wide range of serious
selves construe therapy and its effective in- problems were treated by the surveyed thera-
gredients. Observer ratings represent one pists, including marital problems, depression,
possible viewpoint; the covert feelings and anxiety, child problems, and parent±child
thoughts of family members have still to be problems. Although academic training in
marital and family therapy seemed to result in a comparison group. The size of this effect was
systemic orientation as exemplified by the approximately half a standard deviation, which
tendency of respondents to identify family means that the odds of a treated client doing
and larger system problems, there was consis- better at post-test than a randomly chosen
tency between the respondents and their control client are two out of three. The effect
psychology and social work trained counter- sizes for marital and family therapy were both
parts in the types of client problems treated, the significant and roughly similar. Comparisons
utilization of DSM diagnoses, and the lengths of are hard to make because marital and family
treatment. Simmons and Doherty's overall therapies are offered for the treatment of
conclusion was that the clinical practice patterns different presenting problems. The review
of marital and family therapists were similar to considered specific presenting problems for
those of the other established mental health the family therapy studies and found that
professions. family therapy clients were significantly better
off than control clients for general child conduct
disorders, child aggression, global family pro-
6.04.10 FAMILY THERAPY AND blems, and communication/problem-solving
SYSTEMIC PRACTICE OUTCOME difficulties. Their review included 23 studies
RESEARCH that compared marital and family therapies to
individual psychotherapies. The differences in
In both the UK and the USA there is an outcomes were small and nonsignificant across
increased emphasis on the evaluation and audit a range of presenting problems.
of clinical practices and outcomes, aimed at the Chamberlain and Rosicky (1995), in their
limitation of escalating health care costs whilst review of seven family intervention studies for
improving the quality of care. Family therapists adolescent conduct disorder and delinquency,
have been collecting outcome data for many published since the Shadish et al. (1993) meta-
years. According to Bergin and Garfield (1994), analysis which included 18 such studies, found
marital and family therapy approaches have that family therapy approaches appeared to
been subjected to rigorous scrutiny, with only a decrease adolescent conduct problems and
few other forms of psychotherapy studied as delinquent behavior when compared to indivi-
often. Different outcome studies have reported dual therapy, treatment as usual, and no
the use of single case designs and controlled and therapy, with similar effect sizes of 0.53.
uncontrolled group comparison designs. These Treatment failure in the studies reviewed by
outcome studies have been reviewed by Hazel- Chamberlain and Rosicky correlated highly
rigg, Cooper, and Borduin (1987) and Pinsof with poverty and/or social isolation for the
and Wynne (1995), and using meta-analytic family. The Florida Network Study (Nugent,
techniques by Markus, Lange, and Pettigrew Carpenter, & Parks, 1993) with high risk
(1990) and Shadish, Ragsdale, Glaser, and families found that families who received family
Montgomery (1995). The overwhelming find- therapy were four times as likely to stay together
ings from all these reviews is that family therapy as families who did not, and families who
works compared to untreated control groups, received more than five treatment sessions were
with some demonstrated superiority to standard twice as likely to stay together as families who
and individual treatments for certain disorders did not. So, for these high risk families, family
and populations. Meta-analysis demonstrates therapy may be a necessary treatment compo-
moderate, statistically significant and often nent, but is not sufficient in itself.
clinically significant effects. The research litera- Despite the improvements to methodology in
ture supporting this conclusion is at least as the outcome literature, we are still a long way
robust as it is for other modes of psychotherapy. from answering the specific family therapy
Shadish et al. (1993) conducted a meta- outcome question posed by Gurman, Kniskern,
analysis of 163 randomized experimental com- and Pinsof (1986): ªWhat are the specific effects
parisons of the effects of marital and family of specific interventions by specified therapists
therapy (marital = 62; family = 101) with dis- at specific points in time with particular types of
tressed clients, published up to 1988. Seventy- clients with particular presenting problems?º
one studies compared marital and family (p. 569).
therapy to an untreated control group, and Gale (1980) provided a series of useful
105 compared it to another kind of marital and questions to ask when evaluating the quality
family therapy or to another model of psy- and character of extant family therapy outcome
chotherapy. The number is higher than 163 research, covering issues such as theoretical
because some studies contained multiple com- rational and therapeutic schools, methods of
parisons. The 71 studies showed that therapy training for therapists, pretreatment character-
clients were better off than the untreated istics of clients, techniques of treatment, and
Training and Supervision 101
evaluation of treatment outcome. For example, 1988) and the USA (Liddle, 1991b) have
we might ask: expressed concern at the program-centered
(i) Who has conducted the research, clini- nature of the training and questioned to what
cians or researchers? extent courses address the dilemmas of adult
(ii) Are the studies well designed and free education and adult centered learning, such as
from bias? exploring the relevance of client change pro-
(iii) Are control groups used for different cesses in family therapy to family therapy
types of family therapy, for family therapy and trainees, and learning from the experiences of
other forms of psychotherapy, for family ther- other psychotherapy training courses. In addi-
apy and no treatment control? tion, they point out that courses might do more
(iv) Are the effects of the therapist shown to close the gap between clinicians and
independent of the type of treatment? researchers said to exist in the family therapy
(v) Are the outcome criteria for success and field, by promoting reflective practice models
failure clearly specified? and qualitative research methodology.
(vi) Are multiple outcome criteria used and Research into the effectiveness of family
do they intercorrelate? therapy training has been limited compared to
(vii) Is there a follow-up period and are the the proliferation of regulated training courses.
effects of treatment persistent over time? Avis and Sprenkle (1990) suggest there are many
(viii) What characteristics of families/thera- reasons for this, including the increased com-
pists are associated with success and failure? plexity of the training issues and their relation-
(ix) Are there nonspecific treatment effects? ship to practitioner outcomes, problems of
(x) What is the comparative cost of family sampling and replicability, and a lack of reliable
therapy? Is there a cost to the community for and valid measures of training effectiveness.
failing to provide financial support for family Despite these limitations, Avis and Sprenkle
therapy? conclude from their review of the training
Family therapists have a variety of therapeu- research that conceptual and executive skills
tic approaches to choose from; they are may develop at different rates, that different
concerned increasingly to provide the best training approaches can bring about similar
ªfitº for clients with their particular circum- conceptual and intervention skills develop-
stances and presenting problems, often without ments, that introductory level assessment skills
clear evidence supporting one systemic ap- and concepts can be taught using lectures and
proach over another (Orlinsky, Grawe, & Parks, textbook methods, and that ªin-houseº training
1994). When working therapeutically with courses for agency staff have been shown to be
severe problems, such as adolescent conduct effective in promoting systemic practices and
disorder, there is increasing evidence of the value broadening the remit of mental health services.
of treatment packages, of which family therapy Breunlin and his co-workers (1989) attempted
is a part (Pinsof & Wynne, 1995). to predict which factors might contribute to
improved performance in family therapy trai-
nees before and after training on measures of
6.04.11 TRAINING AND SUPERVISION conceptual, executive, and observational skills.
Interestingly, previous family therapy experi-
Family therapy training courses at both ence did not appear significantly to affect change
introductory and qualifying level have been scores, although prior life experience and
established in the UK since the 1970s, provided maturity did seem to be important, but only in
by family therapy training institutes. All courses changes on measures of executive skills, rather
are accredited by the Association for Family than conceptual and observational skills. Pre-
Therapy. The criteria for qualifying level vious experience as an individual psychothera-
training courses include completed training at pist predicted improvement on conceptual skills
introductory level, 320 academic hours, and 320 change scores, perhaps suggesting that a pre-
practice hours of which 40 are live supervised, vious training prepares trainee family therapists
and a personal development component which for thinking about therapy processes. Pull-
focuses on family-of-origin experiences and eybank and Shapiro (1986) were also interested
their effects on current thinking and practice. in the acquisition of cognitive and therapeutic
Many of the qualifying level courses are behavior skills during family therapy training.
program-centered (Street, 1988) and concerned They suggest that their results indicate a
to identify theories and skills for systemic developmental progression in learning, with
practice within their curricula. Thus, the focus cognitive skills acquired earlier in training,
of training is very much on the process of followed by development in planning and then
teaching. Reviewers of research on family intervention skills. Research by Anderson (1992)
therapy training in both the UK (Street, raised the knotty problem of how to reconcile
differing observer opinions when assessing McDaniel, and Weber (1986) as exploring,
family therapy trainee performance. Anderson contracting, connecting, assessing, implement-
compared the assessments of placement super- ing, evaluating, and leaving. The stages are not
visors, academic supervisors, and so-called mutually exclusive and represent a process that
neutral observers and found more change guides the activity of the consultant. Exploring
reported by placement supervisors than the involves clarifying both the request for con-
ªneutralº observers. The role of evaluation in sultation and who is requesting the consulta-
supervisors' judgments has yet to be system- tion, by considering how the request came
atically researched in the field. about, who approves the request and the role of
Researchers of family therapy training effec- the consultee in the team or organization
tiveness have focused primarily on issues of requesting the consultation. In particular any
skills acquisition, theory±practice linking, and political ramifications of the request are
preparing trainees for systemic practice outside explored. Contracting is the process whereby
of the somewhat protected environment of the agreement is reached on the goals of the
training course. These issues continue to be of consultation, the services provided by the
interest and when we map them on to Gurman consultant, consideration of the risks and
and Kniskern's (1992) predictions for the future consequences of the consultation, procedures
of the field, such as increased diversity of for sharing information, and other practical
intervention formats and methods, increased arrangements. Connecting is the process of
recognition of the importance of the relation- engaging key members of the consultation
ship between the family therapist and the family system in the consultation process and deciding
members, and increased interest in postmodern how they will be involved in goal setting.
developments, the research agenda for training Assessing refers to the methods used for
effectiveness into the first decade of the twenty- gathering information and the systemic con-
first century becomes broader. cepts used to understand the organization's
structure, function, and dynamics. The assess-
ment process particularly focuses on organiza-
6.04.12 SYSTEMIC CONSULTATION tional life cycle issues, recent events triggering
the consultation request, previous attempted
Brunning and Huffington (1990) define solutions to the problem, and the belief systems
consultancy as a direct or indirect process of the consultee. Implementing involves specify-
enabling individuals, groups, or organizations ing the systemic interventions chosen to meet
to fulfill their role, function, or tasks better. It is the consultation request, decisions about
a process by which the person or persons seeking whether education is provided, the means of
the consultation ask for help in identifying or collaborating with the consultee over imple-
clarifying concerns and in considering the mentation and procedures to ensure the main-
options available for problem resolution. Thus, tenance of change. Evaluating is the process of
the consultees have legal, ethical, and admin- deciding how the consultation goals and
istrative responsibility for initiative and action, organizational changes have been met, who
as opposed to supervision where there may well will take part in the evaluation process, plans for
be a hierarchical relationship between the follow-up evaluation, and reflection on the
supervisor and the supervisee, or therapy where process of consultation. Leaving describes the
there is pressure to accept suggestions or means by which a consultation is ended or the
directives in order for the therapy to be effective. consultant renegotiates a different role within
In the case of family consultation, it may well be the organization.
a prologue or alternative to family therapy Campbell (1985) describes an alternative
(Street, Downey, & Brazier, 1991). Wynne, model of systemic consultation specifically
McDaniel, and Weber (1986) discuss consulta- designed to help other family therapists who
tion with families as a process whereby the are ªstuckº in their clinical work with a family.
family members' responsible decision making is He adapts the Milan systemic model of family
assumed and their resources and competence therapy to this task, using theoretical concepts
are directly tapped. The decision as to whom to of meaning, pattern, recursiveness, and differ-
invite to the consultation meetings will depend ence. The consultation interview follows a
largely on where the impasse in the system is similar procedure to a Milan-style family
located. In addition, the systemic view of therapy interview with presession hypothesizing
consultation would see the role of the consultant based on preliminary information, the use of
as a necessary participant in the system circular questioning and reframing, character-
requiring consultation. ized by the neutral stance of the therapist, and
The stages in the process of systems con- midsession breaks for team discussion and final
sultation have been described by Wynne, formulation. The main aim of this style of
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6.05
Psychodynamic Approaches
PETER FONAGY
University College London, UK
6.05.1 THE ORIGINS OF PSYCHODYNAMIC THERAPY 108

6.05.1.1 Definition of Psychodynamic Therapy 108
6.05.1.2 The Short-term Emphasis in Psychodynamic Therapy 108
6.05.2 TECHNICAL ISSUES IN PSYCHODYNAMIC THERAPY 109
6.05.2.1 Suitability for Psychodynamic Therapy 109
6.05.2.2 Formulation of Patients' Problems 109
6.05.2.3 Mechanisms of Defense 110
6.05.2.3.1 The concept of defense in various theoretical frameworks 110
6.05.2.3.2 Primitive defenses 110
6.05.2.3.3 Neurotic and mature defenses 110
6.05.2.4 The Context of Psychotherapy 111
6.05.2.4.1 The therapeutic contract 111
6.05.2.4.2 Abstinence and neutrality 111
6.05.2.4.3 Regression 111
6.05.2.4.4 Resistance 111
6.05.2.5 Transference 112
6.05.2.5.1 The history of the concept 112
6.05.2.5.2 The origin of the transference experience 112
6.05.2.5.3 The limits of transference interpretations 112
6.05.2.5.4 Special forms of transference 113
6.05.2.6 Counter-transference 113
6.05.2.6.1 History of the concept 113
6.05.2.6.2 Types of counter-transference 113
6.05.2.6.3 Counter-transference and interpersonal approaches 114
6.05.2.7 Therapeutic Interventions 114
6.05.2.7.1 Historical overview 114
6.05.2.7.2 Supportive and directive aspects of psychodynamic interventions 114
6.05.2.7.3 Interpretation in psychodynamic therapy 115
6.05.2.8 The Result of Psychodynamic Interventions 116
6.05.2.8.1 The role of insight 116
6.05.2.8.2 The role of working through 116
6.05.2.9 Ending Treatment 116
6.05.2.9.1 Indications for ending treatment 116
6.05.2.9.2 The process of ending treatment 116
6.05.3 ILLUSTRATION OF LONG-TERM PSYCHODYNAMIC THERAPY: PSYCHOTHERAPY FOR
BORDERLINE PERSONALITY DISORDER 117
6.05.3.1 Theoretical Approaches to Borderline Conditions 117
6.05.3.2 Treatment Strategies 117
6.05.3.2.1 Limits and boundaries 117
6.05.3.2.2 Interpretive focus 118
6.05.3.2.3 Counter-transference 118
6.05.3.3 Handling Crises 118
6.05.3.3.1 Desirable outcomes 118
6.05.3.4 Outcome Research 118
6.05.4 FORMS OF BRIEF PSYCHODYNAMIC THERAPY 119
107
108 Psychodynamic Approaches
6.05.4.1 The Historical Roots of Brief Psychodynamic Therapy 119

6.05.4.2 Indications for Brief Psychodynamic Therapy 119
6.05.4.3 Techniques of Brief Psychodynamic Therapy 120
6.05.4.3.1 Malan's brief intensive psychotherapy (BIP) 120
6.05.4.3.2 Sifneos' short-term anxiety-provoking psychotherapy (STAPT) 121
6.05.4.3.3 Davanloo's intensive short-term dynamic psychotherapy (ISTDP) 121
6.05.4.3.4 Luborsky's supportive-expressive time-limited therapy (SETLT) 122
6.05.4.3.5 Strupp's time-limited dynamic therapy (TLDP) 123
6.05.4.3.6 Weiss and Sampson's plan formulation method 123
6.05.4.3.7 Horowitz's person schema theory 124
6.05.4.3.8 Mann's time-limited psychodynamic therapy (TLPT) 125
6.05.4.3.9 Ryle's cognitive analytic therapy (CAT) 126
6.05.4.3.10 Hobson's conversational model 128
6.05.1 THE ORIGINS OF treatment as either an adjunct to pharmacother-

PSYCHODYNAMIC THERAPY apy or as a unique treatment is considerable and
has increased substantially over recent years as a
6.05.1.1 Definition of Psychodynamic Therapy function of cultural, social, and economic
changes (e.g., lessened stigma attached to
The term ªpsychodynamic psychotherapyº
seeking assistance with psychological problems,
covers a somewhat heterogeneous range of
increase in some risk factors for mental illness
psychological interventions which draw their
such as drug and alcohol use) and the greater
inspiration from psychoanalytic theory. Var-
availability of providers (Howard et al., 1996).
ious implementations of this form of treatment
Surveys of the delivery of psychotherapy in
(see Chapter 14, Volume 1) emphasize different
both public and private health care settings
aspects of this rich body of ideas including: (i)
demonstrate that the majority of clients receive
notions of psychic conflict as an all-pervasive
relatively short-term treatment. The majority of
aspect of human experience; (ii) the internal
patients receive less than 10 sessions (DeLeon,
organization of the mind to avoid unpleasure
VandenBos, & Bulatao, 1991; Olfson & Pincus,
arising out of conflict and maximize a sense of
1994), although therapists spend the majority of
the experience of safety; (iii) the use of defensive
their time with the relatively small proportion
strategies for the adaptive manipulation of ideas
(15±20%) who attend more than 26 sessions
and experience to minimize unpleasure; (iv) a
(Howard, Davidson, O'Mahoney, Orlinsky, &
developmental view of psychopathology as
Brown, 1991; Taube, Kessler, & Feuerberg,
arising out of the long-term adverse conse-
1984) and thus may come to believe that long-
quences of adaptations at earlier phases of
term treatment is more common than it actually
development; (v) the organization of experience
is. It should be remembered however that
in terms of the internal representations of
estimates of the mean length of treatment for
relationships between self and other throughout
psychotherapy are reduced by the contribution
the life span; and (vi) the expectable re-
that general (primary care) physicians make to
emergence of these experiences in the relation-
this type of mental health care provision
ship with the therapist. Psychodynamic thera-
(approximately 30%), the majority of whom
pies are predominantly verbal and interpretive
provide extremely brief forms of treatment (one
aimed at the modifications of restructuring of
to three sessions) (Olfson & Pincus, 1994;
the representations of relationships primarily,
Olfson, Pincus, & Dial, 1994).
but not exclusively, through the use of insight.
Managed care, with its declared intention of
cost containment for health care provision,
6.05.1.2 The Short-term Emphasis in requires a more structured, focused, treatment-
Psychodynamic Therapy goal-oriented psychotherapeutic approach
(Brosowski, 1995; Richardson & Austad,
Psychodynamic psychotherapies are rooted 1991). There has been a shift in the formulation
in long-term, time-unlimited approaches, and of the nature of both psychological disorder and
many of the most important advances in theory interventions aimed to address it from an acute
and technique originate from this context. The to a chronic illness model: certain individuals
emphasis in the present chapter will, however, are seen as requiring therapeutic input, briefly,
be on short-term psychodynamic approaches. but repeatedly, throughout the life cycle,
The rationale for this emphasis may be stated as especially in relation to life crises (Cummings,
follows: The demand for psychotherapeutic 1988; Kazdin, 1988; Roth & Fonagy, 1996).
Technical Issues in Psychodynamic Therapy 109
6.05.2 TECHNICAL ISSUES IN attempt to assess the patient's motivation for

PSYCHODYNAMIC THERAPY treatment. This is, however, hard to do as
superficial expression of commitment may or
6.05.2.1 Suitability for Psychodynamic Therapy may not predict the willingness to confront
unpleasant aspects of oneself. For this reason it
Whereas medical treatments tend to have is probably impossible to obtain genuinely
clear indications and contraindications for informed consent in psychodynamic psycho-
specific interventions, the emphasis of assess- therapy research.
ment for psychodynamic therapy tends to More recently, psychodynamic therapists
emphasize the looser notion of general ªsuit- have paid more attention to the nature of the
abilityº (Tyson & Sandler, 1971). Nevertheless, patient's discourse rather than just its content.
some writers have made specific recommenda- Holmes (1995), for example, observes if the
tions concerning suitability for long-term (e.g., patient's narrative styles are markedly avoidant
Coltart, 1988) and short-term therapy (e.g., and dismissing of interpersonal issues or appear
Malan, 1980). While some authors have entangled and enmeshed with them with much
suggested relatively systematic assessment, current anger about past hurts and insults.
which yields both diagnostic and prognostic There is at least one study that shows that the
features (e.g., Kernberg, 1981), in terms of the former type of patient has a somewhat better
developmental level of the patient's personality prognosis in psychodynamic therapy (Fonagy
organization most psychodynamic clinicians et al., 1996). Patients' narrative style may also be
rely on clinical judgments based on interperso- a clue to the extent of their reflectiveness: the
nal aspects of their first meeting with the patient capacity to see oneself from the outside
(Etchegoyen, 1991). The three areas of greatest (Sandler, Dare, & Holder, 1992), autobiogra-
relevance to suitability are: patients' personal phical competence (Holmes, 1992), the ability to
history, content of the interview, and style of reflect on one's inner world (Coltart, 1988), and
presentation. fluidity of thought (Limentani, 1972) are all
In terms of the patient's history, good considered indicators of suitability.
evidence of personal achievement and at least
one good relationship has been traditionally
regarded as a good prognostic indicator 6.05.2.2 Formulation of Patients' Problems
(Malan, 1980). A history of psychotic break-
down, severe obsessional states, somatization, Psychodynamic theory is too diverse to
and a lack of frustration tolerance are normally permit definitive formulations. Formulations
regarded as contraindications. There are many identify central unconscious conflicts, mala-
psychodynamic clinicians who report working daptive defenses, unhelpful unconscious fanta-
successfully with patients who in the past had sies and expectations, deficits in personality
been regarded as unsuitable because of their development and the like. Formulation depends
histories: for example, psychotic (Rosenfeld, on the theoretical orientation of the psychody-
1952), learning disabled (Sinason, 1992), and namic clinician. In Chapter 14, Volume 1 of this
chronically poorly controlled diabetic indivi- work we have reviewed the range of currently
duals (Moran, Fonagy, Kurtz, Bolton, & popular orientations. Agreements, however, are
Brook, 1991). Psychodynamic clinicians treat- hard to reach even when clinicians follow the
ing clients in long-term psychotherapy, parti- same orientation (Horowitz, Rosenberg, Ure-
cularly those working intensively, are more nÄo, Kalehzan, & O'Halloran, 1989). Some
likely to make such risky selections. standardized approaches have, however, been
There is even less agreement about suitability developed (Perry, Cooper, & Michels, 1987;
concerning the content of assessment inter- Perry, Luborsky, Silberschatz, & Popp, 1989).
views. In general, clinicians tend to make their While there is no generally accepted schema
judgment on the basis of the presence of a for formulations, there are several key para-
ªmutualityº between them and the patient and meters that clinicians generally consider. These
observed responses to ªtrial interpretationsº in are: (i) the extent to which representations of
which they attempt to summarize their initial relationships are mature, that is, involve three
impressions concerning the patients' presenting or more persons rather than just a two-person,
problem in the context of their current and past self±other dimension (Karasu, 1990); (ii) the
life situation (see below). In addition, therapists quality of psychic defenses, particularly the
may try to identify if the patient has the capacity predominance of primitive defenses rather than
to respond emotionally within the sessions to more mature ones (Vaillant, 1992, and see
allow feelings of fear, sadness, or anger to come below); (iii) the extent of whole, as opposed to
to the surface (Orlinsky, Grawe, & Parks, 1994). part object relations (where individuals are
Some clinicians, though by no means all, represented as whole persons rather than just an
aspect or a function of a person, e.g., feeding or order to maintain their self-esteem, are using
nurturance, sexual gratification, a container for splitting and projection. Projective identifica-
evacuation) (Kernberg, 1984). tion (Klein, 1946) is also common in this group.
Considerations such as these usually serve Projection, the simple ascribing of an undesir-
two functions. The first of these is to suggest the able mental state to the other, becomes a more
likely effectiveness of the type of treatment: powerful mechanism when the other can be
short vs. long-term, intensive vs. nonintensive unconsciously forced to accept the projection
psychodynamic therapy. On the whole, patients and experience its impact, thus the ªidentifica-
seen as more severe on parameters such as the tionº is in the recipient of the projection. This
three suggested above are less likely to do well current interpretation of the term is particularly
according to most studies of psychodynamic well described by Ogden (1979). It clearly goes
treatment (e.g., Wallerstein, 1986). The second beyond Klein's original meaning: the patient
function of formulations is to give an initial fantasizing that the recipient of the projection
focus to the clinical work, which in the case of acquired a part of the patient's self. Spillius
brief therapy may be the sole focus of the (1994) suggests a helpful clarification; she calls
treatment. In long-term therapy these formula- projective identification which invites the thera-
tions tend to change, sometimes radically, on pist to actualize the projection, ªevocative
the basis of information emerging in the course projective identifications.º
of treatment. Winnicott (1965) referred to Either in fantasy or in actualized form,
psychodynamic treatment as ªan extended form projective identification offers a primitive
of history taking.º method of experiencing control over the other
within a relationship (therapeutic or care-
giving) (Bion, 1955). When parts of the self
6.05.2.3 Mechanisms of Defense are experienced as being within another person,
6.05.2.3.1 The concept of defense in various the individual frequently makes attempts to
theoretical frameworks control these split-off parts by exerting total
control over the recipient or container of the
Within classical theory, which sees conflict as projection. Bion (1962) also stresses that good,
the core of mental function (e.g., Brenner, 1982), as well as undesirable, aspects of the self may be
defenses are seen as adaptations to intrapsychic externalized via this route, making projective
conflict. Within object relations theories, de- identification one of the principle avenues for
fenses are seen as assisting the individual to communication in infancy. Other functions of
maintain an authentic self-representation, a true projective identification, beyond communica-
(Winnicott, 1965) or nuclear (Kohut, 1984) self. tion and control, include: the acquisition of the
Within attachment theory, defenses are seen as object's attributes in fantasy, the protection of a
maintaining desirable relationships (Holmes, good quality from internal persecution by
1993). Within a Klein±Bion frame of reference, evacuating it into an object, and the avoiding
defenses are often conceived of in terms of or denying of separateness. It is thus a
complex structures or systems called organiza- fundamental aspect of an interpersonal relation-
tions. The term underscores the relative inflex- ship focused on fantasy, and its appreciation is
ibility of some defensive structures. Personality critical for adequate psychodynamic psy-
types appear to be characterized by specific chotherapeutic practice.
types of defensive organizations. For example,
in narcissistic disorders idealization and de-
structiveness, the devaluation of genuine love 6.05.2.3.3 Neurotic and mature defenses
and truth, may have been protective at one Anna Freud (1936) is to be credited for the
developmental stage but came to acquire a delineation of most of the mechanisms of
stability which seems to be based on the defense commonly used in clinical formulations
emotional pay-off from this form of adaptation today. It is not possible to give detailed
(Rosenfeld, 1964, 1971; Steiner, 1982). consideration to each of these and most are,
by now, part of common parlance (and exist as
terms of mild rebuke, at least between mental
6.05.2.3.2 Primitive defenses
health professionals). Defenses involving access
Regardless of theoretical orientation, there is to mental representations (e.g., repression) or
general agreement about common forms of the attribution of emotional significance to
defense and their relative sophistication from a these (e.g., denial or disavowal) are perhaps
developmental standpoint (Vaillant, 1992). The most commonly encountered as part of indivi-
primitive defenses tend to be found together in dual coping strategies. For example, jokes
certain individuals. Borderline individuals, who containing emotionally threatening, sexual,
idealize and then derogate their therapists in and aggressive material are notoriously hard
to remember. Denial of the emotional signifi- 6.05.2.4.2 Abstinence and neutrality

cance of incurable disease may be helpful in
Freud (1915) originally wrote about the
increasing the patient's chance of survival
analyst resisting the temptation of gratifying
(Greer, Morris, & Pettingale, 1979). Turning
the patient's sexual desires. Although this is
a response into its oppositeÐterror into
clearly an ethical issue, it also pertains to
aggression (reaction formation)Ðis particularly
analysts forgoing gratifying patients' curiosity,
common in children in response to abuse, and
or using patients to gratify their own personal
identification with the aggressor (becoming the
needs. Equally, the patient undertakes to forgo
tormentor instead of the victim) is common
major life changes where these are currently
amongst maltreated children who become
the subject of psychotherapeutic attention.
abusers in adulthood (Oliver, 1993). Other
Whereas this is particularly important in
commonly noted neurotic defenses include:
short-term treatment, even long-term psycho-
undoing (performing a magical reparative
dynamic treatment can flounder if the emo-
act), intellectualization and rationalization,
tional experiences of the therapy are obscured
and humor.
by the upheavals from major life events.
The diagnostic significance of mechanisms of
Abstinence ensures therapeutic neutrality.
defense is controversial. Some workers claim
Psychodynamic therapists go to great lengths
predictive specificity for such assessments
not to direct their patients' associations and
beyond that of psychiatric diagnosis (Perry
remain neutral no matter what the content of
et al., 1989; Vaillant, 1992). The theoretical
the patients' past experiences or fantasies may
ambiguity which surrounds the concept makes
be. Although this is frequently caricatured, it is
its widespread use as a diagnostic device
important for the psychodynamic therapist to
unlikely, at least in the short term. Its inclusion
retain a certain emotional distance from the
in this chapter is justified by its heuristic value:
client, sufficient for the latter's fantasies and
conceptualizing patients' reactions in terms of
hidden fears to emerge. Needless to say,
defenses makes psychodynamic work practic-
neutrality must be balanced by sensitivity.
able. All of these defenses are common reactions
The recent literature on the working alliance
in psychodynamic therapy, particularly at times
(see below) underscores that the therapist's
of emotionally challenging work. Recognizing
genuine concern for the client must come
them has to become part of the working routine
through if significant progress is to be made.
of the psychotherapist. For example, the
forgetting of material from last week's session
is more common than remembering it, even 6.05.2.4.3 Regression
amongst people whose memory for other, far
more trivial, aspects of their daily life is nothing One aim of psychodynamic psychotherapy is
short of admirable. The psychotherapist recog- to activate and explore aspects of personality
nizes the patient's defenses and mostly uses functioning which are normally obscured
them as an indication of the presence of behind the patient's need to adapt to the
underlying anxiety rather than as occasion for demands of everyday reality. Psychodynamic
confrontation (but see some brief therapeutic therapy, to a degree, encourages access to these
strategies below). representations through the process of regres-
sion. This is less of an active encouragement
than a passive permission. Sandler and Sandler
6.05.2.4 The Context of Psychotherapy (1994) suggested that an ªantiregressive func-
tionº is normally active in all of us, and
6.05.2.4.1 The therapeutic contract psychotherapy can function as a way of
Although contracts are far more relevant for disinhibiting this function in much the same
short-term than for long-term therapy, most way as intimate interpersonal and certain types
psychodynamic therapists explicitly or impli- of large group situations and alcohol appear to
citly convey objectives and expectations to their do. Some therapists consider regression to be an
clients. The details of the agreement usually essential part of successful treatment (Balint,
include time and place, the length and frequency 1949; Winnicott, 1971). Certainly the fear of
of sessions and an initial idea concerning the regression can become an important source of
likely duration of therapy, the expected beha- resistance (Sandler & Sandler, 1994).
vior of the patient and the therapist and so on. It
is the emotional context of this agreement that is
6.05.2.4.4 Resistance
often more important than the items which it
includes. It implies a mutual recognition by Resistance is an essential component of
both parties of the importance placed upon psychodynamic treatment. The word dynamic
protecting the process of therapy. implies the presence of forces rallied against
change. Resistance, like regression, fluctuates in actual relationship; patients see what they
intensity across treatment and may serve expect to see and resist understanding by
different functions at different times and in repeating past relationships in a rigid manner
different individuals. In narcissistic and border- (Levenson, 1983). There is an implication in this
line states, resistance may protect the patient's view of a ªcorrespondenceº between present
self-esteem (Kernberg, 1988; Kohut, 1984); in and past. Many therapists are reluctant to
more neurotic cases it may focus around accept the idea of such a direct relationship. For
preventing the integration of experience (Tho- them transference is an aspect of the patient's
maÈ & KaÈchele, 1987). narrative; it gives ªcoherenceº to the patient's
It may also take different forms. Clients experience of the therapeutic relationship, but it
access to their mental life (e.g., remembering is not an expression of an underlying truth
dreams) may be experienced as restricted about the patient's history (Gill, 1982; Spence,
(repression resistance). Others may wish to 1982). Transference is constructed in the present
keep their relationship with their therapist at an and cannot give us clues to the past. By contrast,
extremely superficial level (transference resis- some who work within a Klein±Bion perspective
tance). Some patients show a paradoxical see transference as a unique window to the
reaction to their treatment: The better it patient's current internal reality (e.g., Joseph,
progresses the worse they feel (e.g., new 1986). For example, confronted with an idea-
symptoms emerge). Freud (1923) attributed lized transference they might see the patient's
this to unconscious guilt. In some patients, at true state as organized around psychotic
least, it is more likely to be linked to their anxieties related to the death instinct. The
pervasive predisposition (envy) to destroy all idealization is a desperate defense against the
things in their life which they experience as good destruction which they fantasize may engulf
but beyond their immediate control (Kernberg, both them and the therapist. Cavell (1994)
1975; Rosenfeld, 1975). demonstrated that the dialectic between these
conceptions of the transference has important
philosophical roots in the debate between
6.05.2.5 Transference ªcorrespondenceº and ªcoherenceº models of
6.05.2.5.1 The history of the concept truth.
Additional suggestions by object relations
The concept of transference originated with theorists have in some ways complicated the
resistance. In his work with the cathartic issue. Here transference is based neither on
method (Breuer & Freud, 1895) Freud initially expectations, defenses against expectations, nor
understood the patient's intense emotional constructions aimed to achieve coherence, but
reaction to the therapist as an interference with rather on a process of externalization of internal
what was an essentially verbal method. He objects (Kernberg, 1984). Such representations
quickly realized that the patient's emotional cannot be seen as true or false; they are distorted
experiences could be better understood as re- by fantasy and defensive processes.
presentations of earlier relationship experiences
(particularly Oedipal strivings and disappoint-
ments) which could be understood in terms of 6.05.2.5.3 The limits of transference
past experience and in fact made that experience interpretations
emotionally more meaningful for the patient There is a further important debate with
(Freud, 1914). regard to the relevance of a transference focus in
psychodynamic therapy. Some therapists are
inclined to see transference as covering all
6.05.2.5.2 The origin of the transference
aspects of the analytic situation. Joseph, (1986)
experience
for example, sees the total situation in the
The patient's intense feelings of anger, therapy as reflecting an internal state of affairs
suspicion, and disappointment, or love, admira- in the patient's mind. Thus other aspects of the
tion, and excitement about the person of the therapeutic relationship, for example, the so-
therapist are unlikely to be a realistic response, called alliance and the so-called real relation-
since two patients may experience such opposite ship, are all subsumed under the transference.
feelings towards the same therapist at similar By contrast, Strachey (1934) conceived of
times. There are currently a range of views about transference as externalization of the patient's
the origin of transference experiences. Some superego. The therapist, unlike other people in
believe that transference is based on actual past the patient's life, does not accept this externa-
experience: the expression of expectations based lization, be it idealized, denigrated, or judg-
on past experiences of relationships (Bowlby, mental, and conveys his or her understanding of
1980). In this view, transference distorts the it by so-called ªmutative interpretations.º This
view implies that the only truly therapeutic in some ways relevant to the patient's current
interpretations are those which involve the experience and thus may be involved in
transference, but clearly admits of other aspects illuminating the patient's reaction or, indeed,
of the relationship. Other therapists, particu- obscuring it. Langs (1976) usefully distin-
larly in the Freudian school (e.g., Anna Freud, guished between counter-transferences which
1936), see transference interpretations as just may be attributed to the patient and those which
one category of interpretive intervention and result from the analyst's neurotic reaction to
give them relatively little particular priority. some aspect of the therapeutic situation.
The concept of counter-transference, like that
of transference, is rooted in the notion of
6.05.2.5.4 Special forms of transference resistance. Freud, throughout his career, never
There are several psychodynamic observa- recognized the value of counter-transference as
tions concerning special forms of transference an indicator of the patient's subjective state
which are helpful to particular groups of (Freud, 1912). Heimann (1950) expanded the
patients. Kohut (1984) described some common usefulness of the concept by pointing out that
transference patterns with narcissistic patients. the therapist's feelings and thoughts about the
Individuals whose self-objects (parents) failed in patient's communications, if reflected upon,
their mirroring function may continue to crave could provide important clues about the
for approbation and admiration and manifest patient's current state of mind. The idea was
this pattern in therapy. This is termed the controversial (e.g., Fliess, 1953) yet it gradually
mirroring transference, which Kohut recom- gained acceptance. Those psychotherapists who
mends the therapist should not puncture by were committed to an interpersonalist tradition
premature interpretations. Idealizing transfer- (e.g., Sullivan, 1953), and saw the relationship
ence similarly aims to meet defective self-esteem aspect of psychotherapy as its most important
by vicariously identifying with the perfect facet, welcomed this expansion of the counter-
therapist. It is a highly controversial recom- transference concept. From their point of view
mendation of Kohut's for therapists to accept the omniscient neutral analyst was an anachro-
such transferences. On the one hand, behind nistic anathema; accepting the analyst's human
such exaggerated accolades may lie deep reaction was a welcome democratic humanistic
frustration and even rage; on the other, if development (Abend, 1989).
Kohut is correct, destroying this image of the
therapist is tantamount to a destruction of the 6.05.2.6.2 Types of counter-transference
patient's self-regard.
Erotic transference is also thought to have Racker (1968) distinguished between com-
infantile roots and occurs relatively commonly plementary and concordant counter-transfer-
in therapeutic relationships, whatever the ence. Concordant counter-transferences are
gender of the therapist and the patient. It tends based upon primitive empathic processes within
to be highly embarrassing for the patient and the therapist. The latter resonates with as yet
sometimes also for the therapist. Most agree unverbalized experiences of the patient. Com-
that it is a distraction and some suggest that it is plementary counter-transferences arise when
a manifestation of a defense against either the patient treats the analyst in a manner
recognizing damage done to the object or the congruent with an earlier relationship pattern.
fragmented state of the self (e.g., Steiner, 1982). King's (1978) notion of ªreverse transference,º
Alternatively, from an attachment theory where patients treat the therapist as they felt
perspective, erotic transference may be a way treated when children, is a special instance of
of forcing the unresponsive object to pay this category.
attention. At the extreme end of this dimension The case of concordant counter-transference
is erotized transference where the demand for particularly raises the issue of the mechanisms
sexual gratification is not experienced by the by which analysts may become aware of the
patient as unrealistic (Etchegoyen, 1991). Such patient's unconscious experience. Sandler
reactions are particularly common in severely (1993) offers the notion of ªprimary identifica-
traumatized individuals. tionº as a rapid process of automatically
mirroring one's partner in a communication
and only becoming aware of this upon reflec-
6.05.2.6 Counter-transference tion. There is good evidence for such a process,
particularly in the infant development literature
6.05.2.6.1 History of the concept
(Osofsky, 1995).
Counter-transference in its broadest sense Only when such primary identifications touch
refers to the thoughts and feelings of the on unconscious conflicts within the analyst,
therapist during a treatment session which are with a consequent mobilization of defensive
processes, will counter-transference start to be a proaches emphasize that it is no longer possible

distorting process. Grinberg (1962) pointed out to consider the therapist's role as ªneutralº or
that such experiences could lead therapists to ªmirror-likeº and that the psychotherapeutic
withdraw from the therapeutic relationship. process is a highly subjective admixture of a
Therapists sensitive to, and resonating with, range of complementary processes that establish
feelings of inadequacy in patients may be made themselves in a unique configuration for each
anxious by such feelings and become defensively therapy.
angry or hypermotivated to show their effec-
tiveness. To some degree this may be an
inevitable part of the process with the therapists 6.05.2.7 Therapeutic Interventions
only gradually understanding the reasons 6.05.2.7.1 Historical overview
behind their unusually defensive style of relat-
ing. Bion (1962) stressed the importance of the There has been a dialectic throughout the
recipient of the projection (the container) being history of psychodynamic approaches between
able to ªmetabolizeº and feed back the products orientations that emphasize insight and inter-
of such primitive communications. Sandler pretation and those that stress the unique
(1976b) pointed out that therapists needed to emotional relationship with the therapist as
allow themselves sufficient freedom of action to the primary vehicle of change. The controversy
be able first to enact the patient's projection and dates back to the earliest days of psycho-
then respond to the enactment in appropriate analysis, to Freud and Ferenczi, but re-emerged
ways. Along similar lines, Brenman-Pick (1985) powerfully with first the work of Balint and
cautioned that the therapists' psychopathology Winnicott set against classical Freudian and
frequently required that they worked through Kleinian theorists, and later Kohut and self
counter-transference identifications so that psychology opposing the classical ego psychol-
their wish not to know was turned into a ogy tradition. This dichotomy is clearly artifi-
potential for knowing. cial, as it is hard to envision effective
Not all counter-transference reactions are psychodynamic therapy without both compo-
provoked by patients' projections or reactions nents (see Wallerstein, 1992). It is nonetheless
to the anxieties that these create. Winnicott helpful in presenting the range of techniques
(1949) was perhaps the first to point out that the used by most psychodynamic therapists which
outrageous provocative behavior of certain span the spectrum between emotional
borderline or psychotic patients produced a relationship-oriented techniques and insight-
normal reaction of ªobjective hate.º Kernberg oriented ones. Winnicott (1971) referred to this
(1984) formalized this, suggesting that such dimension as ªbeing withº versus ªdoing to.º As
behaviors activated primitive aspects of the supportive interventions tend to suggest parti-
therapist's personality. Understanding these cular lines of association, an overlapping
reactions naturally helps the therapist em- dichotomy exists between the use of directive
pathize but it is neither a complementary nor and nondirective techniques.
concordant reaction, nor is it a defense against
affective resonance. It is simply one further
6.05.2.7.2 Supportive and directive aspects of
indication that the therapist too is human.
psychodynamic interventions
There are a whole range of supportive
6.05.2.6.3 Counter-transference and
techniques used more or less deliberately by
interpersonal approaches
psychodynamic psychotherapists. These in-
Modern psychodynamic theory considers clude: explicit support and affirmation; concern
counter-transference as firmly located in the and sympathy (e.g., in response to bereavement
interpersonal field. The patient and psy- or major setback); reassurance, commonly
chotherapist are seen as two mutually influen- concerning irrational anxieties about the ther-
cing psychological systems (Langs, 1978). Both apeutic arrangements; empathy with the pa-
transference and counter-transference are seen tients' painful internal struggles, and so on. The
as the product of a subtle interplay between complexity of such interventions was well
conscious and unconscious systems of both illustrated by Feldman (1993). He showed
patient and analyst. Influences occur in both how patients may experience the therapist's
directions at both conscious and unconscious submission to a demand for reassurance as
levels (Arlow, 1993). Some writers go so far as to anxiety provoking rather than calming, since
suggest that patient and therapist share an they may be unconsciously aware that the
unconscious fantasy of creating an intersubjec- therapist's genuine position is incompatible
tive field between them (Baranger, 1993). with offering such palliatives and are thus faced
Whether correct or not, these modern ap- with the deep fears concerning their own
omnipotence and the therapist's weakness. as implicit criticisms of the patient. Yet early
Nevertheless, Kohut's (1984) emphasis on interpretations of an unconscious wish can be
empathy was undoubtedly a welcome counter- puzzling and confusing even for relatively intact
balance to the rigid interpretive techniques of patients. Furthermore, severely personality
many classical ego psychologists and seems disordered individuals respond poorly to inter-
appropriate with patients who have experienced pretations of the distant past. Their reality
little genuine concern in their history. testing may be too tenuous and they may
Psychodynamic therapists are most likely to overattribute their current experience to past
use supportive and directive techniques which events. It is clearly preferable to work with such
encourage the therapeutic process. Elaborative patients uniquely in the here and now if gross
techniques, such as ªTell me more about that,º distortions of history are to be avoided.
undoubtedly direct the patient's attention to
specific issues and focus the treatment but may
(i) Transference interpretations
be essential precursors to interpretive work
proper. Clarification is also a commonly used Strachey (1934) placed transference interpre-
technique which involves a restatement of the tation at the center of psychodynamic work. As
patient's utterance or just offering a label (a discussed above, his rationale for this was
symbol) for an internal state which the patient constructed as a route out of a vicious cycle of
has limited capacity to represent. Clarifications the external confirmation of the patient's
shade into interpretations and the distinction is repudiation of certain fantasies and feelings.
hard to draw in actual practice. Confrontation Others, however, saw different strengths in
is a subtype of elaboration and clarification. ªworking in the transference.º A focus on the
The therapist, having identified inconsistency, therapeutic relationship offers the patient the
brings this to the attention of the patient, opportunity to internalize the thinking function
usually in a supportive but firm manner (e.g., of the therapist (Hoffer, 1950), the relationship
drawing the patient's attention to the absence of with the analyst as a new object (Klauber, 1972),
affect appropriate to a specific situation). the therapist as a self-object (Kohut, 1977;
Kohut & Wolf, 1978), or adopt a pretend stance
facilitative of the development of an awareness
6.05.2.7.3 Interpretation in psychodynamic
of other minds (Fonagy, 1991, 1995).
therapy
Steiner (1993) pointed to this latter aspect of
Interpretation is the paradigmatic interven- interpretations when he distinguished ªanalyst-
tion. Perhaps not surprisingly therefore it is centeredº and ªpatient-centeredº aspects of
often idealized as the sole or uniquely effective interpretations. When therapists interpret what
method for bringing about psychic change. they imagine to be going on in the patient's mind
Menninger (1958) offered a useful classification they make patient-centered interpretations;
for psychodynamic interpretation. He sug- when they interpret the patient's reactions in
gested that interpretations addressed princi- terms of what they imagine the patient is
pally one of three aspects of a conflict: the thinking about what the therapist is thinking or
defense, the anxiety, or the underlying wish or feeling then this is an analyst-centered inter-
feeling. The content of the interpretation could pretation. Here the patient is directly learning
be further subdivided as concerning current about how minds interact within social relation-
external reality, the transference, and childhood ships (Fonagy, Moran, & Target, 1993).
relationships. Whereas the former type of interpretations, if
The phase of the treatment is most likely to used to excess, may appear to be blaming the
determine the therapist's choice. Commonly patient, the latter type make the therapists
interpretations move from current events appear as if their concerns were purely
through the transference to the distant past. narcissistic and not sympathetic to the patients'
Similarly, generally interpretations start with real difficulties in the external world.
the anxiety, through the identification of the
defense to accessing the repudiated affects. In
(ii) Extratransference interpretations
practice, neither of these patterns can be
considered more than a guideline to be loosely Most psychodynamic clinicians now agree
applied. For example, very long-term therapy that a balance needs to be struck between
often ends up focusing on supportive explora- transference and extratransference interpreta-
tion of current events (Blum, 1989). This is not tions (Stewart, 1989). O'Shaughnessy (1992)
surprising since the distant past can only be evocatively described how a treatment focused
worked over a limited number of times. too much within the transference can become
Similarly, defenses, if interpreted without ªan over-close enclaveº and extratransference
regard to the anxiety, may well come across interpretations had the power to break the
claustrophobic atmosphere. Sometimes, the second to assimilate, and practice working with,
spontaneous and direct communication of the new constructions. It is interesting to note that
analyst's experience of frustration (ªobjective the literature on long-term therapy pays far less
hateº) may help the patient see the therapist as a attention to this aspect of the outcome of
real person and break a repetitive unproductive interventions than the process of interpretation
pattern in the therapy (Coltart, 1986; Syming- which merely is the starting point of the change
ton, 1983). Kernberg (1995) is probably accurate process. Short-term therapies necessarily pay
in saying that patients in the borderline spectrum far more attention to the need to present and re-
benefit specifically from well-structured, here- present psychotherapeutic understanding. The
and-now transference interpretations. relative effectiveness of short-term interventions
may owe much of their potency to the systematic
way in which the task of working through is
6.05.2.8 The Result of Psychodynamic tackled (see below).
Interventions
6.05.2.8.1 The role of insight 6.05.2.9 Ending Treatment
Just as interpretation is paradigmatic but by
6.05.2.9.1 Indications for ending treatment
no means the sole effective component of
psychodynamic interventions, so insight may Like much of psychoanalytic psychotherapy,
be an oft idealized but, in reality, relatively rare the ending of treatment is often idealized. The
outcome of therapeutic work. Insight is the desirable final outcome is often stated in terms
conscious recognition of the role of unconscious of the process of treatment. Kennedy and
factors (feelings, experiences, fantasies) on Moran (1991), following Anna Freud , helpfully
current experience and behavior. ªTrue insightº separate the process aims from the outcome
and mere and intellectual knowledge should be aims of psychodynamic treatment. The former
carefully distinguished (Zilboorg, 1952). ThomaÈ is likely to be stated in theoretical terms (e.g., a
and KaÈchele (1987) identify insight as equidi- move from paranoid to depressive anxieties, an
stant between the poles of pure intellect and increase in the coherence of the patient's
simple emotional experience. Etchegoyen narrative, an increased awareness of impulses
(1991) helpfully distinguished between descrip- and fantasies, a manifestation of genuine
tive or verbal insights on the one hand and concern for others and so on). All these are
ostensive or shown insights on the other. The observed in the context of the treatment and are
latter is a more direct form of knowing and at best loosely coupled with the goals the patient
pertains to the common experience when one is might have for ending the treatment.
in emotional contact with an event one has The latter are often external changes such as
known before. the decline of symptoms, improvement of
There is general agreement that insight is an relationships, decrease of unpleasant affect,
integrative experience (ThomaÈ & KaÈchele, an increased capacity for assertiveness, and so
1987). Those who follow a Klein±Bion model on. These external criteria are sadly regarded by
would describe this as a healing of defensively many psychodynamic clinicians as superficial as
instituted splits in the patient's mental repre- they can be achieved without fulfilling the
sentations of others and their relationships to process aims of the treatment (GruÈnbaum,
them (e.g., Segal, 1962). In more general terms, 1984). Evidence will have to be gathered which
it may be seen as an instance of a more general clearly demonstrates that external change
predisposition to think in terms of the mental associated with process change is more extensive
states of one's objects and understand one's or longer lasting than external changes achieved
relation to them in mental state terms (Fonagy in isolation.
& Target, 1996). This tendency may also be
described in terms of a willingness to see the
interpersonal world from a ªthird-person 6.05.2.9.2 The process of ending treatment
perspectiveº (Britton, 1989, 1992). There is general agreement that ending
treatment is ªa process.º Different authors
identify different processes: a new beginning
6.05.2.8.2 The role of working through
(Balint, 1949), weaning (Meltzer, 1967), mourn-
Neither intellectual nor emotional insight is ing (Klein, 1950), detachment (Etchegoyen,
sufficient for progress (Freud, 1914). The 1991), and maturation (Payne, 1950). An
function of working through is to help the inevitable part of ending is disillusionment with
patient to practice a newly arrived-at integra- not having achieved the ideal (Pedder, 1988),
tion. This has two components: first, to unlearn and the loss of the object who has been the
the implications of prior misconceptions, and receptacle for projections (Steiner, 1993). As
Illustration of Long-term Psychodynamic Therapy 117
part of this process, symptoms might return, if A critical feature from the point of view of
briefly, and problems already worked through treatment is the high prevalence of trauma in
may appear to resurface. Most clinicians agree this group. A large proportion of hospitalized
that other than acknowledging the unconscious borderline individuals meet diagnostic criteria
issues around ending, no specific technical for post-traumatic stress disorder (PTSD)
maneuvers are indicated. (Gunderson & Sabo, 1993) and 70±80% have
histories of severe physical or sexual abuse
(Herman, Perry, & van der Kolk, 1989). The
6.05.3 ILLUSTRATION OF LONG-TERM almost ubiquitous presence of trauma may help
PSYCHODYNAMIC THERAPY: bring together conflict or deficit theories,
PSYCHOTHERAPY FOR particularly since the trauma is frequently one
BORDERLINE PERSONALITY of relatively late childhood or even adolescence.
DISORDER It is conceivable that certain individuals whose
6.05.3.1 Theoretical Approaches to Borderline early attachment relationships were insecure,
Conditions and who are consequently somewhat poorer at
understanding mental states in others and in
Psychodynamic theories of borderline per- themselves, when confronted with an abusing
sonality disorder (BPD) are discussed exten- relationship respond to it by selectively oblit-
sively in Chapter 14, Volume 1 and only a brief erating detailed representations of the mental
summary of these views will be presented here. states of other attachment figures (Fonagy et al.,
Broadly there are two approaches to under- 1995). A number of common features of
standing this relatively rare but troublesome borderline personality disorder could be ex-
disorder characterized by intense but unstable plained in terms of the defensively deactivated
personal relationships, self-destructiveness, im- mentalizing capacity of such individuals in the
pulsivity, poor social adaptation, self-damaging context of attachment relationships (e.g., con-
behavior or suicidality, chronic dysphoria, fusion in interpersonal relationships, apparent
transient psychotic episodes, and so on. There callousness towards others, poor capacity to
are those who suggest conflict as the central communicate).
theme and those who favor an explanation in
terms of deficit. 6.05.3.2 Treatment Strategies
The conflict model is best represented by the
Klein±Bion tradition (e.g., Steiner, 1993) as well It is to be expected that two sets of theoretical
as by the work of Kernberg (1984). A key approaches (conflict and deficit) lead to cate-
feature of these formulations is the unsuccessful gorically different treatment recommendations.
integration of good and bad part-objects, and The former identifies the early interpretation of
the use of primitive defenses (particularly the negative transference as critical, whilst the
projective identification and idealization and proponents of the deficit view stress the
derogation). It is assumed that children cannot importance of the holding environment and
deal with excessive aggression arising from empathic responding. There is no shortage of
abandonment experiences and are forced to forceful recommendations and warnings of the
split again and again their internal representa- dire consequences should these not be followed
tions to protect their internal sense of good. By (e.g., Kernberg, 1984; Ryle, 1994), but evidence
contrast, deficit models ascribe the internal supporting either position is at the moment
fragmentation of borderline patients to depri- sparse. A number of reviews have, however,
vation experiences which leave the ego weak and brought together a generic framework for the
unable to self-soothe. Consequently such in- psychodynamic treatment of borderline pa-
dividuals draw on exogenous stimuli such as tients based on the assumption that both
drugs, binge eating, or self-harm to induce conflict and deficit models are of relevance
mood states (Adler, 1985). Narcissistic features and both would probably cause harm if
which accompany borderline states are seen by inexperienced therapists were to follow the
Kernberg as representing the conflict between recommendations without qualification (see
the individual's need for an object and the rage Gabbard, 1994; Higgitt & Fonagy, 1992;
felt towards that object. They deal with the Waldinger, 1987).
conflict by self-absorbedly becoming their own
ideal self. For Kohut (1977) and Winnicott
6.05.3.2.1 Limits and boundaries
(1965) absent, insensitive, or abusive primary
figures force children to retreat into themselves The therapist needs to recognize the impor-
and become the missing ideal object. In both tance of both setting definite limits for patients
cases infantile omnipotence is maintained into and the patients' likely failure to keep to
adulthood. traditional boundaries. The setting must be
protected from the overwhelming demands reserve for themselves for thinking. Mindless
which such difficult patients may produce, yet anxiety or a bewildered state of numbness can
must have the flexibility to contain the patients fill not just the session itself, but times for
at times when self-regulatory capacities are no reflection before and after.
longer available to them. As these remarks
suggest, there are major advantages to seeing 6.05.3.3 Handling Crises
the more severe cases in institutional (although
not necessarily inpatient) rather than private Crises in treating borderlines are inevitable
settings. but their timing may well be a surprise. The
general advice of those who regularly deal with
6.05.3.2.2 Interpretive focus emergencies across a wide range of contexts is
that disaster planning is best when it precedes
Psychological space must be created in the rather than follows the event. A well-rehearsed
mind of the patient for interpretive work which contract with a patient may go some way to limit
assumes mentalizing (thinking about mental extremes of acting out, but having a plan for
states in self and other). It is essential that dealing with suicidality, self-harm, drunken-
moment-to-moment changes in affective states ness, intrusiveness, and sometimes violence is
are noted and clarified by the therapist, even if the key. Knowing what to do will avoid acting
the reason for these rapid changes of affect often out on the part of the therapist which mostly
remains obscure. Failures of understanding are takes the form of aggressive, overpunitive,
often reacted to rather dramatically (with rejecting actions arising mainly out of damaged
complete withdrawal, paranoia, physical vio- self-esteem: ªHow can you do this to me when I
lence, self-harming). The interpretation (more have tried so hard with you?º Good collabora-
properly clarification) of these emotional reactive relationships with colleagues also working
tions at their earliest stages may avoid a vicious with the patient is a sine qua non of psychothera-
cycle of ever-increasing anger and ever-decreas- peutic treatment.
ing possibility for genuine understanding. The management of crises, however, cannot
Therapists should aim to make be mechanistic. Careful scrutiny with the patient
ªmicrointerpretationsºÐsimple but frequent of thoughts and feelings that led up to the event
verbalizations which address states-of-mindÐ must take place even if not at the time and not as
using words to make room for thinking and part of the emergency procedures. The over-
feeling without making assumptions that at arching goal is replacing action with mental
times of intense affect the patient can under- work. Despite there being no foolproof way of
stand complex causal relations between mental preventing crises, certain patterns of therapeutic
states. It should be remembered that the intervention (e.g., excessive passivity, complete
destruction of thought might be the strategy nondirectiveness, or other expressions of rigid-
closest to hand for many of these patients and ity and unthinking conduct) will inevitably
thus, unless cautious and nimble, the therapists cause these patients to incubate anxiety and
may well find themselves squeezed out of the ªblow.º
therapeutic space, where there is now no longer
room for any kind of understanding. 6.05.3.3.1 Desirable outcomes
6.05.3.2.3 Counter-transference The goals of long-term psychodynamic
therapy are ambitious in some contexts but
Feelings with borderline patients are intense. have to be modest with borderline patients. The
From one meeting to the next, ªtherapist the process goals are largely clustered around the
saviorº may turn into ªtherapist the tormen- notion of tolerance: tolerance for affect, for
tor.º At these moments several things are hard fantasy, for a variety of therapeutic interven-
to remember. First and most obvious, that there tions (particularly therapist errors). The ex-
is no truth in either attitude and that all that is ternal goals are also limited. Although anxiety
certain is that nothing is permanent. Second, may abate, depression rarely responds signifi-
that there is some painful element of truth to cantly. Interpersonal issues may improve but
even the wildest projection and that the never become normal. The behavioral aspects
therapist is a real cause as well as an imaginary are most likely to respond to treatment.
one. Third, that any pretense of being un-
affected by the close proximity of such intense 6.05.3.4 Outcome Research
emotion creates an atmosphere of unauthenti-
city, not just between therapist and patient but Evidence for the efficacy of psychodynamic
also within the therapist. Unfortunately, the therapy for borderline individuals is limited. A
patients' intolerance of other minds causes them long-term naturalistic follow-up (Stone, 1993)
to attack the space which therapists usually of 500 patients demonstrated some degree of
Forms of Brief Psychodynamic Therapy 119
spontaneous remission in middle life but also ium. There is no difficulty in incorporating
high suicide rates and selective response to these methods into modern psychoanalysis
treatment. Clearly, the DSM diagnosis de- (Fonagy, 1989; Wachtel, 1977), just as Ferenczi
scribes several subgroups of patients probably had little difficulty in so doing. His discoveries
with somewhat different etiologies and sig- included the principle of exposure to combat
nificant differences in expected outcomes. phobic avoidance, the principle of response
Work at Cornell Medical Center by John prevention for obsessional rituals, and the
Clarkin, Otto Kernberg, and colleagues may focused elaboration of key ideas akin to some
provide us with a questionnaire instrument strategies of cognitive therapy. Ferenczi 's aim
which will assist in the assessment of suitability. in these and other elaborations was to accel-
Treatment drop-out rates are very high, in one erate the process of change. Neither he nor
sample up to 50% (Aronson, 1989). Patients Otto Rank shied away from the possibility of
who stay in treatment appear to do relatively using techniques from other therapeutic mod-
well with success rates of 60±70% reported alities (e.g., hypnosis) if these were going to
from open trials (Rosser, Birch, Bond, Den- advance their underlying aim of enhancing the
ford, & Schachter, 1987; Stevenson & Meares, curative emotional experience of psychody-
1992; Stone, 1993). namic therapy (Ferenczi & Rank, 1925,
pp. 63±64).
Franz Alexander was influenced by Ferenczi
6.05.4 FORMS OF BRIEF in his training. Together with Thomas French,
PSYCHODYNAMIC THERAPY he elaborated Ferenczi's suggestion of provok-
6.05.4.1 The Historical Roots of Brief ing specific affective experiences in the ther-
Psychodynamic Therapy apeutic relationship. They advocated that the
therapist should purposefully counteract the
Paradoxically, the prototypical long-term pathogenic influence of particular significant
psychodynamic therapy, psychoanalysis, shares figures from the past. For example, the
its roots with brief therapy. The psychoanalytic accepting attitude of the therapist may contrast
treatment of many of the pioneers of psycho- with that of an excessively harsh and author-
analysis would by present standards be con- itarian parental figure. The choice of the
sidered brief, intensive psychotherapies. The therapist's attitude should be dictated by the
early cathartic method advocated in Breuer and history of the specific patient. Even more
Freud (1895) may be construed as a focused important than these controversial suggestions
hypnotic brief intervention. Freud's case load, is the general framework advanced by Alex-
even after his discovery of the method of free ander and French which included a structured
association, contained brief therapy cases approach initiated by a detailed assessment
including some very distinguished clients, followed by a comprehensive formulation, the
Bruno Walter and Gustav Mahler amongst setting of treatment goals, and the systematic
them. anticipation of problems that may be encoun-
Three of the early generations of psycho- tered in the course of treatment. The total
analysts sharing Hungarian origins contributed treatment package included homework assign-
most directly to brief psychodynamic interven- ments, a focus on current relationships, and an
tions. These are Otto Rank, Sandor Ferenczi, open acceptance of educational as well as
and Franz Alexander. Both Rank and Ferenczi insight-related goals of therapy.
were concerned that long-term therapy could
reinforce regressed overdependent aspects of 6.05.4.2 Indications for Brief Psychodynamic
the client's personality and that the goal of Therapy
psychoanalytic research through the in-depth
exploration of the patient's psyche may at times The diagnostic groups that are likely to be
conflict with the immediate aim of addressing considered for brief psychodynamic therapy are
the abnormal dynamics of the patient's mental the less severe anxiety and depressive disorders,
life (Ferenczi & Rank, 1925, p. 52). Ferenczi adjustment disorders, and some of the milder
was particularly keen to discover ways in which personality disorders. By contrast, individuals
the process of symptomatic cure could be with a history of suicidal threats, alcohol and
accelerated. In the course of this research he substance abuse, poor impulse control, incapa-
discovered many of the central principles of citating depression or anxiety, or dramatic
behavior therapy. Because of the conservative cluster personality disorders are normally
nature of the psychoanalytic establishment, deemed unsuitable (Messer & Warren, 1995).
these remained outside the psychodynamic Proponents of brief therapy normally add
frame of reference and became a major psychodynamic criteria to the phenomenologi-
challenge rather than part of its armamentar- cal. Sifneos (1987) for example, suggested that,
in addition to a circumscribed central com- 6.05.4.3 Techniques of Brief Psychodynamic

plaint, suitable clients would have a history of at Therapy
least one good childhood relationship, a
6.05.4.3.1 Malan's brief intensive psychotherapy
capacity to relate flexibly to the interviewer,
(BIP)
evident psychological mindedness and a moti-
vation for change beyond symptom relief. By David Malan, a British psychoanalyst work-
contrast, Malan (1976a) lists six dynamic ing at the Tavistock Clinic alongside one of the
exclusion criteria which are the mirror image pioneers of object relations theory, Michael
of Sifneos' selection criteria: for example, the Balint, was one of the first to adapt standard
inability to make contact, lack of motivation for psychodynamic therapy as practiced in this
treatment, rigid defenses and severe depen- psychoanalytically oriented outpatient public
dence. Davanloo (1980) emphasizes the impor- mental health facility for brief interventions
tance of ªtrial interpretations.º If clients (Malan, 1963, 1976a, 1976b). The normal length
respond to firmly put, but necessarily tentative of BIP is approximately 20 sessions. In the initial
hypotheses by a ªdeepening involvement,º they session(s) central conflicts for the patient are
are more likely to be regarded as suitable than identified and the therapist focuses on these
individuals whose response is decompensatory selectively, ignoring other conflicts and inter-
(e.g., anxiety, confusion, paranoia). preting only those aspects of the patient's
Strupp and Binder (1984) also list current material which pertain to these concerns. There
emotional discomfort. They suggest that pa- is no particular type of conflict to which Malan's
tients have to be sufficiently uncomfortable with approach gives preference, although Malan
their feelings and/or behavior to seek help from offers an overriding structure, similar to that
psychotherapy. On the whole, brief psy- of Karl Menninger, which he regards as
chotherapists recommend expressive techniques pertinent to all conflicts. The ªtriangle of
for healthier patients and supportive techniques conflictº includes: the impulse or affect, the
for sicker ones (Luborsky & Mark, 1991). defense erected against it, and the symptom or
No formal, structured interviews and assess- anxiety which ensues after the failure of defence.
ments have been developed to aid clinicians in An example (Malan, 1980, pp. 178±184) of a
these assessments. There is, however, significant focal conflict may be someone who is angry
empirical data available which suggests that about being imposed upon but defends against
some of these psychodynamic parameters are this and manifests usually intense anxiety about
pertinent to the likely success of psychotherapy. asserting herself and becomes depressed as a
Piper and his colleagues have, however, carried consequence. Malan recommends addressing
out a number of excellent studies validating conflict in at least three contexts: in the patient's
some of the underlying concepts. Piper, de current life, with the therapist, and in relation to
Carufel, and Szkrumelak (1985) demonstrated past caregiving figures.
that the quality of object relations (QOR) and Perhaps because of its proximity to standard
defensive style together predicted good outcome psychotherapeutic practice, Malan's Brief In-
in time-limited psychodynamic therapy. The tensive Therapy has been extensively validated
clinical judgment of the quality of object empirically. Malan's own studies (Malan,
relations is based on an evaluation of the 1976a, 1976b) are methodologically too weak
quality of object relation patterns throughout to warrant review. However, the Canadian
the life span, the capacity to regulate affect and studies by Piper have provided evidence that (i)
self-esteem, and historical antecedents of these Malan's therapy is as effective as long-term
(Piper et al., 1985). individual or group psychotherapy (Piper,
Quasi-experimental studies demonstrated Debbane, Bienvenu, & Garant, 1984), (ii)
that clients with high QOR were more likely patients undergoing this form of therapy are
to benefit from therapy than low QOR ones to a significantly better off in 78% of cases than
clinically significant extent (Piper, Azim, untreated control patients (Piper et al. 1990),
McCallum, & Joyce, 1990a). QOR may be a and (iii) that for highly object-related patients
better predictor of therapeutic alliance than the accuracy of transference interpretations
measures of interpersonal functioning but may corresponded to outcome at six-month follow-
account for the latter's association with out- up (Piper, Joyce, McCallum, & Azim, 1993).
come (Piper et al., 1990). Norwegian studies Norwegian studies demonstrated that level of
have independently demonstrated that a clinical insight gained (as assessed independently) in 43
assessment of the patient's quality of inter- outpatients correlated with overall dynamic
personal relations was a good predictor of long- change at four-year follow-up (Hùglend, En-
term change following dynamic psychotherapy gelstad, Sùrbye, Heyerdahl, & Amlo, 1994).
(Hùglend, 1993a, 1993b; Hùglend, Sùrlie, There are controversial findings concerning
Heyerdahl, Sùrbye, & Amlo, 1993b). the role of transference interpretations. Malan
reported that the frequency of therapist, parent, There is only very limited evidence available
current figures triangular interpretations corre- to support the usefulness of this approach.
lated with therapeutic outcome (Malan, 1963, Sifneos and colleagues reported a comparison
1976b). This finding corresponds to Strachey 's of 22 treated patients and eight waiting list
classical assumptions concerning ªmutativeº controls (Sifneos, Apfel, Bassuk, Fishman, &
aspects of interpretation (Strachey, 1934). Gill, 1980). While 18 out of 22 were reported to
Unfortunately, although preliminary replica- have recovered in the treated group or to be
tions confirmed Malan's observations (Marzia- much better, none of the waiting list group
li, 1984; Silberschatz, Fretter, & Curtis, 1986), reported a similar degree of change. In a
more careful analyses by the Canadian group somewhat larger study reported in 1987, 30 of
indicated that, for low QOR patients at least, 36 patients were rated as having recovered or
the frequency of transference interpretation was being much improved whereas 80% of the 14
associated with less rather than more symptom waiting list patients were unchanged. Unfortu-
change (Hùglend et al., 1993a; Piper, Azim, nately in neither study were the measures
Joyce, & McCallum, 1991). sufficiently clearly described to permit general-
An interesting study by another Norwegian ization, nor were raters blind as to treatment
research group has demonstrated the effective- group. Independent studies examining the
ness of Malan's BIP in reducing the relapse rate relationship of therapeutic process to outcome
following clomipramine treatment of panic found no evidence that therapists' competence
disorder (Wiborg & Dahl, 1996). Thus Malan's at practicing STAPT predicted good outcome.
therapy is relatively well validated although the In fact, competence was inversely related to
clinical groups on which the treatment was improvement (Svartberg & Stiles, 1992, 1994).
assessed are relatively heterogeneous. Studies
also offer some indication that the treatment
process corresponds to those hypothesized by
6.05.4.3.3 Davanloo's intensive short-term
the originator of the therapy, although evidence
dynamic psychotherapy (ISTDP)
on this point remains equivocal.
Davanloo's approach is also quite confronta-
tional, aiming to create a degree of emotional
6.05.4.3.2 Sifneos' short-term anxiety-
arousal and even discomfort while trying to
provoking psychotherapy (STAPT)
address presumed feelings in clients which they
In the USA, short-term psychodynamic might have consistently avoided (Davanloo,
psychotherapy retained close links with the 1978, 1980). Davanloo's aim is to intensify the
classical ego psychology tradition. Sifneos emotional charge of the therapeutic situation so
developed a psychodynamic treatment focused that within it important past emotionally
on the oedipal concern of individuals whose charged experiences will once again come to
psychological problems could be relatively life. The therapeutic strategy entails offering
readily linked to this common type of uncon- empathic support in relation to the past hard-
scious conflict (Sifneos, 1979, 1987, 1992). ships suffered by the patient. Nevertheless, the
Sifneos, probably accurately, pointed out that pattern of interaction as revealed by Davanloo's
psychodynamic therapists were frequently more detailed account is one of tenacious and
ready to acknowledge issues of dependency and unremitting confrontation of the patient, fo-
frustration in relation to caregiving figures than cused on the patient's problems and defenses
concerns about childhood sexual fantasies against them, identified on an initial inquiry.
about parents of the opposite gender. The There is a single trial which supports the
recommended strategy is for the therapist to effectiveness of this form of therapy (Winston
listen carefully for material pertaining to et al., 1991). Thirty-two patients were assigned
oedipal issues and to address this directly to one of two brief psychodynamic therapies.
without regard to the defenses which individuals Patients assigned to the other therapy (brief
may have erected to protect themselves from the adaptive psychotherapy) did comparably to
anxieties these thoughts might engender. those receiving ISTDP and both did substan-
Sifneos adopts a somewhat didactic stance tially better than the waiting list controls. In a
and does not shrink from explaining his follow-up and extension of this investigation
reasoning in identifying material as relating to (Winston et al., 1991, 1994) a larger sample of
oedipal anxieties. He also confronts patients' patients were seen to maintain their improve-
defenses, being particularly sensitive to in- ment. An interesting feature of this investiga-
stances of intellectualization. A strong point tion was the inclusion of some nondramatic
of his approach is the availability of a relatively Axis II patients. The study, however, only used
comprehensive manual for short-term anxiety- self-report measures and did not succeed in
provoking psychotherapy (Sifneos, 1992). differentiating the two forms of psychotherapy.
6.05.4.3.4 Luborsky's supportive-expressive proach that the frequency of conflict themes

time-limited therapy (SETLT) negatively correlated with measures of change
(Crits-Christoph & Luborsky, 1990).
Luborsky's brief psychodynamic approach is The second component of Luborsky's ap-
fundamentally an adaptation of psychodynamic proach is the helping alliance. In addition to
therapy defined quite broadly (Luborsky, 1984). attending to current, past, and transference
The technical principles are outlined by Lu- relationship fears, therapists are required,
borsky and Mark (1991). They include recom- through their timing and restraint in responding
mendations for the therapist to be sensitive to interpretively to clients' material, to convey
allow the patient to form a ªhelping alliance,º to respect, acceptance, realistic optimism, to en-
identify and respond about central relationship courage self-expression and thus create a
patterns, and identify where the client's symp- collaborative atmosphere (Luborsky, 1984,
toms fit into these. They explicitly recognize the pp. 81±89). The helping alliance thus generated
patient's needs to test the relationship in has two dimensions according to Luborsky: the
transference terms and recommend that the patient perceives the therapist as a provider of
patient's symptoms should be identified as help that is needed, and the patient perceives the
problem-solving coping patterns. therapy as a collaborative exercise (Luborsky,
Thus, Luborsky's approach has two critical Crits-Christoph, Mintz, & Auerbach, 1988).
focuses. The first is the relationship patterns Helping alliance has been shown to be
which they label as ªcore conflictual relation- positively associated with outcome. The duality
ship themesº (CCRTs) (Luborsky & Crits- of Luborsky's approach (CCRT and helping
Christoph, 1990). These themes consist of three alliance) is supported by critical findings that the
components: the wish (or need), the anticipated quality of the helping alliance and therapist
response from others to this wish, and the accuracy (as defined in terms of the degree of
response from the self to the other's response. correspondence with the CCRT) independently
These themes are conflictual because the predict outcome (Crits-Christoph, Barber, &
response of the other to the wish is anticipated Kurcias, 1993; Crits-Christoph, Cooper, &
to be negative. The CCRT is derived from Luborsky, 1988). In the more recent study,
clinical material. ªRelationship episodesº are there was an indication that accuracy of early
identified from transcripts of sessions where the intervention had a positive impact later on in
patient narrates an episode of interaction. The therapy. Thus it is possible that whilst the quality
CCRT represents a summary of the most of the helping alliance may be the immediate
frequent types of components. Luborsky and cause of change, this aspect of the relationship
Schaffler (1990) offer an illustration of an may be enhanced by accurate formulations by
individual whose wish is to be assertive, the therapist.
dominant yet reassured, but anticipates dis- Although no randomized controlled trials
approval and is left feeling annoyed, angry, and compare Luborsky's supportive-expressive
upset about not feeling in control. It is therapy with no treatment controls for milder
important to note that relationship episodes neurotic disorders, the Penn project yielded
may be drawn from narratives which apparently numerous important findings concerning the
do not involve the self, and in this respect the outcome of this treatment. Most impressively,
method is analogous to psychodynamic psy- three-quarters of the large group of patients
chotherapists' approach to the understanding of treated showed moderate or much improvement
the transference. with an average effect size of over one standard
Considerable research supports the value of deviation, and much of this gain was maintained
CCRTs (see Luborsky & Luborsky, 1995). The at one-year follow-up (Luborsky et al., 1988).
reliability of both the overall formulation and its In addition, in a major study comparing
components is relatively high when performed supportive-expressive therapy, cognitive ther-
by trained judges (Crits-Christoph, Luborsky, apy, and drug counseling for opiate-dependent
Popp, Mellon, & Mark, 1990). The measure is patients, Woody and his colleagues (Woody,
also replicable across settings. The CCRT with Luborsky, McLellan, & O'Brien, 1990; Woody
the therapist parallels the CCRT for others in et al., 1983; Woody, McLellan, Luborsky, &
the patient's life (Fried, Crits-Christoph, & O'Brien, 1987) found supportive-expressive
Luborsky, 1990) and even the CCRT derived therapy to be effective in reducing psychiatric
from patients' dreams (Popp, Luborsky, & symptoms, opiate-positive urine specimens,
Crits-Christoph, 1990). The extent of these employment, and legal problems. In a replica-
observed congruencies indicates that these tion study the same group demonstrated that
patterns of representations of relationships supportive-expressive therapy was a useful
are stable structures of the personality. It is adjunct to drug counseling as part of a typical
an important validation of Luborsky's ap- community-based drug program (Woody,
McLellan, Luborsky, & O'Brien, 1995). It is daptive patterns (Binder & Strupp, 1991, p. 142).
notable that supportive-expressive therapy was The Vanderbilt University Project, of which
particularly helpful in maintaining improve- Strupp's TLDP is a product, was key in
ment at follow-up. Although studies on de- identifying the therapeutic relationship and
pressed or anxious individuals would be helpful, the nature of the patient's experience with this
it is clear that supportive-expressive therapy is a new figure as a key aspect of therapeutic change.
valuable intervention strategy. An important finding of the project was that
successful treatments could be predicted on the
basis of the patient feeling accepted, under-
6.05.4.3.5 Strupp's time-limited dynamic
stood, and liked by the therapist as early as the
therapy (TLDP)
third session of treatment (Hartley & Strupp,
The hallmark of Strupp's model of therapy 1983; O'Malley, Suh, & Strupp, 1983; Windholz
lies in its interpersonal emphasis and the & Silberschatz, 1988). The importance of the
persistent use of the transference relationship relationship is further underscored by the
in the here and now. The therapy has its absence of an observed significant difference
intellectual roots in Sullivan's (1953) interper- between trained psychotherapists and sensitive
sonal psychoanalytic tradition. Binder and but untrained college professors in their ability
Strupp (1991) understand psychopathology as to administer time-limited dynamic therapy
arising out of cycling maladaptive patterns (Strupp & Hadley, 1979).
whereby patients perceive themselves in mala-
daptive roles with self-defeating expectations,
6.05.4.3.6 Weiss and Sampson's plan
negative self-appraisals and adverse affects
formulation method
consequent on these. The cyclical nature of
the process arises out of the client's unconscious Weiss and Sampson (1986) proposed a
tendency to induce others to behave in ways that further useful framework for the articulation
reinforce the patient's negative and painful of clinical focus. At the core of the theory is the
expectations, thus further reinforcing these assumption that patients enter therapy with an
expectations and the interpersonal behaviors unconscious plan about how they may over-
which arise from these. This formulation is close come their problems with therapeutic help.
to that proposed by Joseph Sandler in the 1970s Pathogenic beliefs are ªobstaclesº to this. Weiss
and early 1980s (Sandler, 1976b, 1990, 1992). and Sampson assume that patients will inevi-
Similarly to Luborsky, Binder and Strupp tably ªtest,º in the context of their therapy,
(1991) distinguish actions of the self, expecta- whether their pathogenic beliefs are true. If the
tions about others' actions, acts of others therapist ªpassesº the test, the patient's experi-
towards the self, and acts of the self towards ence will contribute to the enlargement of
the self. Although these terms sound somewhat understanding (ªinsightº) to counteract the
behavioral, from their description it is clear that pathogenic belief. An example of a pathogenic
the authors are concerned with mental repre- belief may be an individual with a mother
sentation of these interpersonal behaviors unhappily married throughout the patient's
rather than the behaviors themselves. The childhood, unconsciously believing that her
cyclical maladaptive patterns are identified by happiness means that her mother will feel hurt
the therapist on the basis of the client's and abandoned. The patient might then test the
characteristic patterns of relating which involve therapist to see if the therapist also expects the
the patient's perception of self, others, and their patient to be self-sacrificing and feigns hurt if
interactions. In therapy, maladaptive patterns the patient attends ªselfishlyº to her own needs.
are identified, their meaning interpreted and the Such an unconscious belief arises out of actual
client is helped to articulate and modify historical experience, rather than an uncon-
entrenched and limiting views of the self, others, scious wish to harm the mother (Sampson, 1992,
and their interaction. p. 515).
TLDP creates individualized theories for It follows that the principal therapeutic task
each client, making use of these four headings. of short-term dynamic psychotherapy is that the
The theories connect together behavioral and therapist should recognize the patients' con-
experiential phenomena which otherwise would scious or unconscious attempts to replicate with
appear discontinuous (Strupp & Binder, 1984). the therapist their pathogenic situations or past
The patient's relationship with the therapist is life experiences. Therapists may be deemed to
seen as a key component of the change process. pass the patient's test by giving recognition of
This new relationship may disconfirm mala- the situation through appropriate interpreta-
daptive expectations of others and provides a tion or nonverbal behavior, such as maintaining
chance to examine the way that patients' acts their therapeutic stance despite the patient's
towards the self may ensnare them in mala- determination to traumatize and unsettle them.
Thus the nonoccurrence of certain strongly RRMs are organized into affectively coherent
anticipated outcomes may in and of itself be configurations (RRMCs) each of which are
therapeutic. made up of RRMs with a set of wishes, fears,
Research, building on this approach, has and defenses in relation to a specific theme.
demonstrated that plan formulation may be Desired RRMCs contain strong wishes, and
reliably assessed using recorded clinical material dreaded RRMCs are made up of feared RRMs.
(Curtis, Silberschatz, Sampson, & Weiss, 1994; The derivatives of defensive operations are
Curtis, Silberschatz, Sampson, Weiss, & Rosen- compromise RRMs which can be either adap-
berg, 1988; Silberschatz & Curtis, 1993) and that tive (if successful) or problematic (if not), but in
such plans are stable over time (Collins & either case the affective valence of the RRM has
Messer, 1991). The compatibility of the ther- been attenuated. A problematic RRMC will
apist's interventions with independently as- contain either negative affects or maladaptive
sessed plans of the patient was found to traits, at a more manageable level than in
predict progress in the early and middle phase dreaded RRMs. If the enactment of a desired
of therapy (Messer, Tishby, & Spillman, 1992). RRM is blocked by the threat of entry of a
One of the strengths of Weiss and Sampson's dreaded RRM, an attenuated solution to the
approach is that it may be assumed to apply to desired RRM is found which provides a partial
patient's behavior, regardless of the orientation gratification of the wish. An RRMC may
of the therapist. Indeed, the Plan Compatibility represent a firm linkage between RRMs so that
of Interventions Scale predicts response to a mental state organized by a desired RRM can
therapist intervention in cognitive-dynamic, as trigger a mental state organized by a dreaded
well as object-relations theory-based ap- RRM. Such mental states may be represented
proaches (Tishby & Messer, 1995). It should by patterns of activation, such as those
be noted that in these studies outcome refers to envisaged in parallel distributed computer
relative improvements within the therapeutic models of neural activity.
process rather than overall improvements at the Horowitz (Horowitz, 1991a; Horowitz, Frid-
end of therapy. In fact, no large-scale study of handler, & Stinson, 1991) views anxiety as a
Weiss and Sampson's method has as yet been mismatch between schemas and incoming
undertaken. information. If information is interpreted as
suggesting a dreaded schema, anxiety will result.
If a wished-for RRM is to be in relation with a
6.05.4.3.7 Horowitz's person schema theory
powerful guiding figure but this brings with it a
Horowitz (1988a, 1988b, 1991a) has offered a dreaded RRM of a state of exploitation, the
general systems theory reformulation of object individual will experience anxiety at the moment
relations constructs strongly influenced by of being approached by an actually benign but
Bowlby's (1973, 1980) notion of internal work- powerful figure because this person's presence
ing models, Sandler's (1976a, 1976b) notion of brings with it the threat of exploitation. This
role responsiveness, and Kernberg's (1975, may put control processes in place which will
1984) model of self±object dyadic units, as well reduce the distance of this figure. The anticipa-
as current cognitive science. He proposes that tion of the dreaded RRM is experienced as
through development the individual evolves anxiety without the dreaded RRM ever being
multiple schemas of self and other which exist fully activated (i.e., coming into awareness). The
either as person schemas or as role-relationship control processes can, in the extreme, become
models (RRMs). He defined the former as severe enough to imply personality disorder, in
nonexperiential (codifications and) meaning this case perhaps a somewhat schizoid state.
structures with the potential to influence the In certain cases the dreaded RRM may be
formation of the self-concept. They are seen as partly experienced and this is also expected to
combining in more complex schemata of the lead to anxiety. A woman who lost her husband,
self-in-relationship-with-the-other (see also whom she felt was dependable but whom she did
Stern, 1994). The self-schemas integrate the not love, may develop anxiety when she starts a
individual's prior experiences and, ideally, relationship with another man for whom she has
present a stable image of the self as invulnerable. more intense feelings. The dreaded RRM which
These RRMs are templates of relationships is briefly activated is the experience of seeing
which can affect the formation of the concept of herself as the unfaithful wife humiliating her
relationships as well as actual patterns of dependable but unexciting husband (see Hor-
interpersonal transactions. RRMs are assumed owitz, 1991a).
to specify interaction patterns as sequences, In post-traumatic stress disorder an experi-
much like scripts of plays, but in terms of ence is vividly encoded in memory. Because it is
expectations, wishes, and appraisals of one not integrated into the individual's prior
person toward the other. integrated self-schema, it is liable to be activated
as incoming information, and misinterpreted to iously. He believes that the time limitations
imply the reoccurrence of the trauma. The inevitably brings into the foreground the
trauma may also threaten to actualize a dreaded difficulty most of us experience with separation
RRM, for example, of the self as weak and (Mann, 1973). Time-limited psychotherapy is
overwhelmed. The compromise state may be focused on the patient overcoming separation±
denial, depersonalization, restricted affect, and individuation issues through the mastery of
hypervigilance (see Horowitz, 1986, 1988a). In separation anxiety. The conflicts encountered in
generalized anxiety disorder the dreaded RRM this context concern independence, activity,
is seen as inescapable, either because a com- self-esteem, and delayed grief. Mann suggests
promise cannot be reached or because the that the beginning of therapy recreates a
desired RRM contains some dreaded compo- symbiotic unity, the middle phase recreates
nents (e.g., RRM of the self as blundering and ambivalence, whilst the end phase introduces
stupid in face of punishing mentors in a the necessity to give up the object, but this time
situation which is experienced as one of without hatred, anger, despair, or guilt.
constant evaluation). Mann's formulation focuses on clients'
Horowitz's model is most extensively feelings about themselves in relation to the
elaborated for the 12-session treatment of painful events described. He acknowledges the
post-traumatic stress disorder (Horowitz, patients' active coping efforts and their experi-
1986, 1991b). The therapy is aimed at the ence of failure with regard to being able to adapt
realignment of RRMs. In the ªintrusive repe- adequately to this distress. Patients' symptoms
titive phase of the stress responseº the recom- are not directly addressed but rather the
mended strategy is largely supportive and underlying emotional state, particularly their
ameliorative. The therapist takes on the aux- injured self-esteem, is highlighted. In contrast to
iliary ego function of self-regulation and the Sifneos and Davanloo, Mann is not at all
reduction of overwhelming affect states. In the confrontative and uses confirming and mirror-
ªdenial numbing phaseº of the stress response, ing to bypass defenses rather than tackling them
Horowitz emphasizes the reduction of controls head on (Mann & Goldman, 1982). The therapy
over self-expression and emotional exploration. lasts 12 sessions excluding sessions for history
The stress event remains the therapeutic focus, taking. The initial phase of four sessions sets up
serving to organize the therapist's activities in an alliance generating hope and frequently a
relation to the transference and other feared remission of symptoms. In the middle phase
topics. Time limit and termination are also ambivalence sets in as patients come to
explicitly identified as themes to be addressed recognize that their unconscious expectations
from as early as session six. will not be fulfilled. In this phase the therapist is
Horowitz's model stands out among psy- no longer simply mirroring and affirming but is
chodynamic formulations for brief therapy in introducing clarifications, mild confrontations,
offering a comprehensive framework specific and interpretations especially regarding the
for a range of psychiatric disorders at the same current situation of the person's life and thus
time as remaining amenable to empirical directly reinforcing the patient's separateness.
examination. Clinical judges appear to be able In the final four sessions the patient's reactions
reliably to assess roles, characteristics, and traits to termination are the focus. The therapist
of self and others, link them in wish-fear attempts to build a sense of mastery and
dilemmas, and assemble them into presumed competence at the same time as addressing
RRMCs of particular patients observed in the patient's disappointment and ambivalence
psychotherapy sessions (Horowitz, Milbrath, concerning separation, often linked to past
Reidbord, & Stinson, 1993; Horowitz, 1995; experiences of inadequate resolutions of separa-
Horowitz & Eells, 1993). There appears to be tion and loss.
considerable convergence between RRMC for- In this therapy the time-limited nature of the
mulations and Luborsky's core conflictual intervention is used directly to elicit a set of
relationship theme approach (Horowitz, Lu- conflicts associated with earlier separations and
borsky, & Popp, 1991). Unfortunately, ran- losses where maladaptive emotions were gen-
domly controlled outcome studies on erated (anger, disappointment, sadness, guilt)
Horowitz's therapeutic strategies are lacking. which ultimately resulted in the disorder which
led to the referral. The therapy creates a
situation where separation can occur with a
6.05.4.3.8 Mann's time-limited psychodynamic
degree of resolution which is less contaminated
therapy (TLPT)
by negative emotions. The internalizations thus
Of the brief psychodynamic therapies it is lead to a less angry, more benign introject.
perhaps Mann's approach that takes the time- Although Mann's therapy is well-established,
limited nature of the intervention most ser- it has not yet generated a great deal of research.
A notable exception is a study reported by engage in monitoring their symptoms, undesir-

Shefler and colleagues (Shefler, Dasberg, & able behaviors, and mood shifts. Neurotic
Ben-Shakhar, 1995). This was a randomized patterns are described in terms of three
controlled trial with a waiting list control categories: dilemmas, traps, and snags. Dilem-
design. Only nine out of the 33 patients did mas, traps, and snags are described in the
not have a DSM diagnosis. The effect size was ªpsychotherapy fileº which is given to patients
only fractionally below one on a range of at the end of the first session. They rate items
measures. However, the patients accepted for within it to indicate how characteristic they are
the trial were highly selected and only 11% of of them. These ratings are discussed at
those seen were included in the trial. In an subsequent sessions when main target problems
uncontrolled trial, Joyce and Piper (1990) found (TPs) are also established, on the basis of the
that 14 patients diagnosed with separation- self-monitoring, together with the underlying
individuation problems were highly successfully dilemmas, traps, and snags. Traps are things we
treated in 12 sessions using Mann's technique cannot escape from, such as ªa fear of hurting
and the results were maintained at six-months othersº trap, ªtrying to pleaseº trap, or ªsocial
follow-up. There is further evidence that TLPT isolationº trap. Dilemmas are false choices
reduces drop-out rate (Sledge, Moras, Hartley, about oneself or about one's relation to others,
& Levine, 1990), and patients who do well show for example, ªeither I feel I spoil myself and am
a trend towards increasingly appreciating their greedy or I deny myself things and punish myself
sessions as the treatment progresses (Joyce & and feel miserableº or ªeither I am a brute or a
Piper, 1990). martyr.º Snags are ways we stop ourselves from
Mann's approach has been criticized for changing, for example, ªfor fear of the response
attempting to provide a generic model on the of others.º The dilemmas, traps, and snags
basis of a specific model of pathogenesis characteristic of an individual are the target
(Grand, Rechetnick, Podrug, & Schwager, problem procedures (TPPs) which are thought
1985; Westen, 1986). Some fundamentally to underlie that person's central problems.
disagree that termination is an inevitable crisis ªTPsº and ªTPPsº form the agenda of the
in therapy (Quintana, 1993). It is also unlikely therapy. The remaining sessions (usually once a
that Mann's model of cure is accurate. A process week over three months) are devoted to
such as internalization is more likely in long- recognition of the TPPs using diaries and other
term than in short-term therapy (Westen, 1986). self-monitoring devices as well as close mon-
However, although the treatment is only itoring of the client's behavior in the therapeutic
appropriate for a relatively limited group of situation. Modification of TPPs is principally
patients, its very specificity may be its strongest achieved through behavioral techniques such as
feature. If a method was found to identify this role play, as well as enhanced self-reflection.
group using reliable operational criteria which The explicit noncollusive relationship with the
also matched concerns of purchasers of mental therapist is also thought to facilitate the
health care (e.g., generalized anxiety disorder), development of new procedures.
this form of therapy could be a valuable Ryle (1985) incorporated object-relations
component of the repertoire of psychodynamic theory into CAT introducing the notion of
approaches. reciprocal role procedures. These are thought to
develop on the basis of early object relation-
ships. It is assumed that a relationship teaches
6.05.4.3.9 Ryle's cognitive analytic therapy
children both the behaviors expected of them
(CAT)
and the behaviors they expect of others. Self-
Relatively unknown in the USA, but increas- management is learned through incorporating
ingly influential in the UK, is CAT, a time- into the child's behavioral repertoire the
limited integrative psychotherapy (Ryle, 1982, caretaker's behaviors.
1990). The procedural sequence model (PSM) is The emphasis in CAT is on early and
the framework used by Ryle to restate psycho- profound deprivation as the cause of primitive
analytic ideas using cognitive language. The defenses such as splitting, which characterizes
model conceptualizes intentional acts as proce- individuals who fail to integrate their self-
dures entailing a series of steps including structure and elicit confirmations from others
appraisal of plans and predicted consequences, for each of their split-off self states. Whereas
the evaluation of the consequences of the neurotic clients restrict or distort their proce-
enactment, and the confirmation or revision dures, borderline personality disorder patients
of aims and means following this evaluation. manifest dissociated self-states containing dif-
The therapeutic method is centered on the ferent procedures in each.
process of reformulation. Over the course of the Therapists summarize their assessments and
first month of the treatment, patients normally present it to the client in writing after the fourth
session. These summaries represent client relations. An example may be a powerfully

history and present circumstances and trace rejecting inner parent relating to a submissive
how current problematic procedures could be and needy inner child. The reciprocal nature of
repetitions of early harmful patterns or are the role patterns encompass psychodynamic
solutions to early situations. The accounts concepts such as identification, introjection,
conclude with a list of problem procedures and projection, internal objects and part-
identified and attempt to anticipate how these objects. Roles which are experienced as unten-
may influence the course of therapy. A further able are projected, that is induced in the other,
tool used in CAT is the sequential diagramatic and can be replaced by symptomatic procedures
reformulation (SDR) which is a flow diagram or defensive ones. Procedures acquire their
representation of how TPPs maintain neurotic stability from confirming reciprocations which
patterns. are generally readily elicited from others, thus
Thus CAT is a genuine integration of leaving the central core repertoire unchanged.
cognitive therapy (Beck, 1976) and object- While Ryle and others writing from a CAT
relations theory-oriented psychodynamic ther- perspective are keen to acknowledge Soviet
apy (Ogden, 1986). The approach to psycho- theoreticians such as Vygotsky, Bakhtin, and
dynamic diagnosis is similar to many considered Leonjew (e.g., Leiman, 1994a), their views are
above, particularly Luborsky and Horowitz. consistent with psychoanalysts writing in the
The therapeutic techniques suggested are in- interpersonalists' tradition (e.g., Mitchell,
novative and share much with schema-oriented 1988).
cognitive therapy where emotional problems The key difference between CAT and tradi-
are seen as the reactivation of schemas which tional psychodynamic therapy is the shift from
have been dormant for many years (Beck & interpretive work to description. The CAT
Freeman, 1990; Bricker & Young, 1993; Young, therapist describes the state of affairs, often in
1990). Ryle's integration also has much in writing, which is then subject to discussion and
common with other integrative models such as modification in direct therapeutic conversa-
Gold and Wachtel's ªcyclical psychodynamics,º tions. Ryle repudiates interpretive techniques as
which also emphasizes self-maintaining vicious potentially regression-inducing, reflecting an
cycles and intra- and inter-psychological pro- unbalanced power relationship between client
cesses and structured intervention techniques and therapist and feeding on the omnipotent
(Gold & Wachtel, 1993). Safran (1990a, 1990b) fantasies of the therapist (Ryle, 1992, 1993).
also links concepts of interpersonal schema and Ryle's approach lends more weight to conscious
the cognitive interpersonal cycle, and the processes and his technique is based on insight
therapy program outlined has as its target the coupled with the activation of self-corrective
disconfirmation of dysfunctional interpersonal mechanisms. It is striking that, notwithstanding
schemas. CAT, however, is far more coherently the emphasis on such mature mental processes,
integrated with the traditional psychodynamic Ryle and his colleagues have reported signifi-
formulations than any of these alternatives (e.g., cant successes in the brief psychotherapeutic
1992; Leiman, 1994b; Ryle, 1994). treatment of borderline personality disorder. In
The procedural sequence object relations an ongoing study, BPD patients are offered up
model (PSORM) illustrates the thoughtfulness to 24 sessions of CAT and follow-up sessions at
of this integration. The PSORM identifies one, two, three and six months. There is a three-
procedural patterns which explain the persis- month and one-year follow-up. Initial results
tence of neurotic behavior. For example, self- are promising (Ryle, 1995). Eight out of 13
destructive acts may be attributed to a dilemma patients no longer meet BPD criteria four
(ªas if I must harm myself or harm othersº) or to months after termination but seven were
a snag (ªas if guilty and therefore self-punish- rereferred for a variety of other treatments.
ingº). Within SDR the self-maintaining nature Five patients assessed at one year all showed
could be clearly demonstrated through the continuing reductions in symptomatology and
connection between procedures. For example, only one has remained in treatment.
the expectation of abandonment may generate a A number of other outcome studies support
dilemma between being involved and thus the usefulness of CAT. A study of 48 out-
risking abandonment and avoiding closeness. patients randomly assigned to 12 sessions of
Being involved thus necessitates procedures for CAT or Mann-type brief therapy demonstrated
controlling emotionally significant others by the superiority of CAT on a grid measure of
compensatory procedures such as bulimia, that change of construing problems (Brockman,
are seen as a substitute for emotional emptiness. Poynton, Ryle, & Watson, 1987). Unfortu-
The PSORM postulates reciprocal role patterns nately the measure was neither standardized nor
which constitute a central core and are stated in sufficiently independent from the treatment to
terms of inner parent±inner child (IP±IC) justify firm conclusions. A study of poorly
controlled diabetics randomized 32 patients to 32% partially maintained their gains, and 11%
intensive education or CAT (Fosbury, 1994). At relapsed. No differences were found between
nine-months follow-up CAT-treated patients cognitive-behavioral and psychodynamic ther-
had better diabetic control in terms of HbAlc apy, although patients who only received eight
levels. Other studies were either uncontrolled sessions of psychodynamic therapy did less well
clinical reports (e.g., Cowmeadow, 1994; than those who received eight or 16 sessions of
Duignan & Mitzman, 1994; Pollock & Kear- CBT.
Colwell, 1994) or yielded insignificant differ- While this particular form of therapy is
ences between CAT and control treatments neither widely known nor widely practiced, it is
(e.g., the outpatient treatment of anorexia; Ryle, unique in terms of having been subjected to a
1995). Thus the empirical basis of CAT cannot rigorous randomized, controlled trial. As the
yet be considered well-established (although methods used in Hobson's conversational
relative to many other psychodynamic treat- model are fairly generic and consistent with
ments its empirical status is highly favorable). most psychodynamic approaches, the Sheffield
psychotherapy trial provides encouraging evi-
dence for the value of brief psychodynamic
6.05.4.3.10 Hobson's conversational model
approaches for the treatment of one of the most
An approach which integrates many of the common disorders, major depression.
characteristics of the brief psychodynamic
approaches considered above is the conversa-
tional model outlined by Hobson and his 6.05.5 CONCLUSIONS
colleagues (Goldberg et al., 1984; Hobson,
1985). The approach combines psychodynamic, This chapter has reviewed psychodynamic
interpersonal, and experiential concepts, and approaches to adult mental health problems.
emphasizes the therapist±client relationship as Psychodynamic therapy is most appropriate for
the main vehicle for revealing and resolving individuals with psychiatric disorder who are
interpersonal difficulties. In contrast to a relatively well-functioning and have a capacity
number of other short-term therapies, therapists to understand and respond to interpretive work.
are encouraged to present their views as The chapter reviewed key clinical concepts in
tentative statements rather than assertions psychodynamic work and demonstrated an
and to make clear that these are open to increasing concern among psychodynamic clin-
correction and modification. The therapy is icians with feelings and ideas provoked by the
conceived of as an interpersonal negotiation, therapeutic situation itself. Long-term psycho-
with therapists inviting elaboration of their dynamic therapy was illustrated in the review of
ideas by the patient, as well as feedback. The therapeutic strategies with individuals with a
language of the treatment is one of mutuality, borderline personality disorder diagnosis. Sev-
with the therapist putting forward hypotheses eral forms of brief psychodynamic therapy were
concerning the client's experiences and possible discussed, together with evidence for their
relationships between these. The therapy has effectiveness.
been manualized as part of the Sheffield No single approach to such brief treatments
Psychotherapy Project under the direction of emerged as clearly superior to others. While
David Shapiro (Shapiro & Firth, 1985). there is a surprising amount of empirical work
A unique outcome study by Shapiro and which has been performed over recent years, few
colleagues (Shapiro et al., 1994) assessed the of the studies appear to be conclusive. But,
effectiveness of this mode of intervention, taken together, they underscore the merits of the
contrasting it with cognitive-behavioral therapy psychodynamic approach. There is good evi-
in a sample of 117 patients. Both therapies were dence that psychodynamic therapy is effective
administered for either eight or 16 weeks. with depressed, substance abusing, and some
Overall, both therapies were found to be mixed groups of neurotic patients. There are
effective and to have comparable results. There indications of its appropriateness for indivi-
was an interaction between initial symptom duals with PTSD, physical illnesses such as
level and duration of therapy. Patients with diabetes, and even BPD. Clearly much empirical
severe depression showed significantly better work remains to be done to identify which of
outcomes when they received 16 weeks of these treatments has the greatest potential value
therapy. Eighty-eight percent of the sample for which patient group.
were followed up one year after the end of Work over the last few decades, however,
treatment (Shapiro et al., 1995). Of the 103 goes a considerable way towards overcoming
patients, 52% were defined as treatment many of the weaknesses frequently noted in
responders (remained asymptomatic for four connection with this approach. A number of
months). Of these, 57% maintained their gains, psychodynamic clinicians have done extensive
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6.06
Psychopharmacology
PHILIP J. COWEN

6.06.1.1 History of Drug Treatment in Psychiatry 136
6.06.1.2 Mode of Action of Psychotropic Drugs 137
6.06.1.3 Pharmacokinetics of Psychotropic Drugs 138
6.06.1.4 Prescribing Psychotropic Drugs 138
6.06.2 CLASSIFICATION OF DRUGS USED IN PSYCHIATRY 139
6.06.3 ANXIOLYTIC DRUGS 139
6.06.3.1 Benzodiazepines 139
6.06.3.1.1 Pharmacology 139
6.06.3.1.2 Compounds available 139
6.06.3.1.3 Adverse effects 140
6.06.3.2 Azapirones 140
6.06.3.3 Other Drugs Used to Treat Anxiety 141
6.06.3.3.1 Antidepressant drugs 141
6.06.3.3.2 Antipsychotic drugs 141
6.06.3.3.3 b-Adrenoceptor antagonists 141
6.06.4 HYPNOTIC DRUGS 141
6.06.4.1 Compounds Available 141
6.06.5 ANTIPSYCHOTIC DRUGS 141
6.06.5.1 Pharmacology 142
6.06.5.2 Compounds Available 142
6.06.5.2.1 Typical antipsychotics 142
6.06.5.2.2 Atypical antipsychotic drugs 142
6.06.5.3 Adverse Effects 143
6.06.5.3.1 Movement disorders 143
6.06.5.3.2 Autonomic and endocrine effects 143
6.06.5.3.3 Neuroleptic malignant syndrome 144
6.06.5.3.4 Other adverse effects 144
6.06.5.3.5 Adverse effects of clozapine 144
6.06.5.4 Dosage of Antipsychotic Drugs 145
6.06.6 ANTI-PARKINSONIAN DRUGS 145
6.06.6.1 Preparations Available 145
6.06.6.2 Adverse Effects 145
6.06.7 ANTIDEPRESSANTS 145
6.06.7.1 Mechanism of Action 146
6.06.7.2 Tricyclic Antidepressants 146
6.06.7.2.1 Pharmacological properties 146
6.06.7.2.2 Adverse effects of tricyclic antidepressants 146
6.06.7.2.3 Amoxapine 147
6.06.7.2.4 Clomipramine 147
6.06.7.2.5 Lofepramine 147
6.06.7.2.6 Maprotiline 148
6.06.7.3 Selective Serotonin Reuptake Inhibitors 148
135
136 Psychopharmacology
6.06.7.3.1 Pharmacological properties 148

6.06.7.3.2 Efficacy in depression 148
6.06.7.3.3 Unwanted effects of SSRIs 148
6.06.7.4 Monoamine Oxidase Inhibitors 149
6.06.7.4.2 Compounds available 149
6.06.7.4.3 Efficacy of MAOIs in depression 149
6.06.7.4.4 Unwanted effects 149
6.06.7.4.5 Interactions with foodstuffs and drugs 149
6.06.7.4.6 Moclobemide 150
6.06.7.5 Other Antidepressant Drugs 150
6.06.7.5.1 Mianserin 150
6.06.7.5.2 Mirtazapine 151
6.06.7.5.3 Trazodone 151
6.06.7.5.4 Nefazodone 151
6.06.7.5.5 Venlafaxine 151
6.06.7.5.6 Bupropion 152
6.06.7.5.7 L-Tryptophan 152
6.06.8 MOOD-STABILIZING DRUGS 152
6.06.8.1 Lithium 153
6.06.8.1.2 Efficacy 153
6.06.8.1.4 Toxic effects 154
6.06.8.1.5 Lithium and pregnancy 154
6.06.8.2 Carbamazepine 155
6.06.8.2.2 Efficacy 155
6.06.8.3 Sodium Valproate 155
6.06.8.3.2 Efficacy 155
6.06.9 CLINICAL USE OF PSYCHOTROPIC DRUGS 156
6.06.9.1 Anxiety Disorders 156
6.06.9.1.1 Generalized anxiety disorder 156
6.06.9.1.2 Panic disorder and agoraphobia 156
6.06.9.1.3 Obsessive-compulsive disorder 157
6.06.9.1.4 Social phobia 157
6.06.9.2 Insomnia 157
6.06.9.3 Depression 157
6.06.9.3.1 Choice of antidepressant 157
6.06.9.3.2 Prophylaxis of recurrent major depression 158
6.06.9.3.3 Psychological therapies and antidepressant drug treatment 158
6.06.9.4 Mania 158
6.06.9.5 Prophylaxis of Bipolar Illness 158
6.06.9.6 Schizophrenia 159
6.06.1 INTRODUCTION disorder. Drugs are also commonly used to treat

less severe illnesses, such as depressive and
It is only since the late 1940s that drug anxiety disorders. Wherever drug treatments are
treatment has been able to play a useful role in used, they should form part of an overall
the management of psychiatric disorders. Little management plan that takes into account
is known about the pathophysiology of psy- psychological and social needs of the individual
chiatric illness, and the drugs that are currently patient and their family.
in use were discovered by chance or by
modification of compounds known to be
efficacious. Indeed, such neurochemical the- 6.06.1.1 History of Drug Treatment in
ories as there are of psychiatric disorder have, in Psychiatry
the main, been derived from a knowledge of the
pharmacological effects of psychotropic drugs Drugs that produce changes in the function of
in animal experimental studies. the central nervous system, such as opiates and
Drug treatment now plays in indisputable anticholinergic agents, have been used in the
role in management of severe psychiatric treatment of mental disorders for hundreds of
disorder, such as schizophrenia and bipolar years. Although some of these drugs may have
Introduction 137
had calming effects, they were of no specific We are also learning much more about how these
value in the treatment of psychiatric disorders. chemical messengers may modify behavior
Particular drug treatments tended to be used through their interactions with specific brain
because their cause was espoused by vigorous regions and distributed neuronal circuits.
and eminent physicians rather than on the basis The availability of novel compounds, likely to
of proven efficacy. In any case, assessment of have a quite different range of behavioral effects
efficacy depended on uncontrolled clinical compared to currently available drugs, will lead
observation. to some exciting developments in psychophar-
The first drug that was discovered to have a macology. It seems probable, given the com-
specific effect on a prticular psychiatric disorder plexity and multifactorial origin of psychiatric
was lithium (Cade, 1949; Table 1). Lithium is a disorders, that detailed knowledge of etiology
toxic agent and Cade's important clinical and pathophysiology, may lag behind advances
observations did not make a significant impact in therapeutics. This, of course, is not uncom-
on clinical practice until the following decades mon in general medicine but serves to reinforce
when controlled trials showed that lithium was the importance of controlled clinical trials in the
effective in both the acute treatment of mania assessment of new psychopharmacological
and the prophylaxis of recurrent mood dis- treatments.
orders. In addition, monitoring of plasma
lithium levels enabled safe dosing regimes to
be established. 6.06.1.2 Mode of Action of Psychotropic Drugs
Since the late 1960s there has been a period of
consolidation in psychopharmacology during Psychotropic drugs act in one way or another
which clinical trials have been extensively on the process of chemical signaling, a mechan-
employed to refine the indications of particular ism employed by the brain for the purposes of
drug treatments and to maximize their benefit communication between neurones. Neurones
risk ratios. New compounds have continuously make connection with each other at specialized
become available but because, in the main, these regions of the cell membrane called synapses.
agents have been derived from previously Chemical transmission at synapses occurs when
described agents, their range of activity is not a chemical messenger or neurotransmitter is
strikingly different from their predecessors. In released from one neurone and interacts with a
general, however, the newer agents are better specific binding site or receptor on an adjacent
tolerated and are sometimes safer, and both neurone. In general, psychotropic drugs act to
these developments are important for clinical increase or decrease the impact of a neuro-
practice. transmitter on its receptor. This can be achieved
It is, perhaps, possible now to be more in a number of ways (Table 2).
optimistic about the prospects for advances in Much is known about the pharmacological
psychopharmacology. There is, for example, effects of psychotropic drugs in experimental
rapidly increasing knowledge about the nature animal studies. However, it is much less clear
of chemical signaling in the brain. A multiplicity how such pharmacological changes are trans-
of neurotransmitters and neuromodulators lated into therapeutic benefit in patients with
interact with specific families of receptors, many psychiatric disorders. Studies in healthy volun-
of which exist in several different subtypes. teers may not be helpful in elucidating this issue.
Several of these receptors have been cloned and For example, a therapeutic course of an
selective agents for them are becoming available. antidepressant drug has no effect on the mood
of an individual who is not depressed. A further
complication is that most psychotropic drugs
Table 1 Introduction of some drug treatments in take a number of weeks before their full clinical
psychiatry. effect becomes apparent (Table 2). From this it
has been deduced that the therapeutic effect of
Year Drug treatment drug treatment is likely to be due to slowly
evolving adaptive changes in neurotransmitter
1949 Lithium mechanisms and the neuronal circuits that
1952 Chlorpromazine depend on them. (A review of the mechanisms
1954 Benzodiazepines of drug action is given by Stahl 1996.)
1957 Iproniazid (MAOI)
When a patient has responded to psycho-
1957 Imipramine
1971 Carbamazepine tropic drug treatment it is usual for drug therapy
1980 Selective serotonin reuptake inhibitors to be continued for some time. Where a disorder
1988 Clozapine for treatment-resistant is believed to run a self-limiting course, for
schizophrenia example a single uncomplicated episode of
major depression, it is customary to withdraw
Table 2 Mechanism of action of some psychotropic drugs and time to onset of therapeutic effect.
Drug Action Time to onset of action
Antidepressant Increase action of noradrenaline and serotonin 2±4 weeks

Antipsychotic Block dopamine receptors 2±6 weeks
Anxiolytic (benzodiazepine) Increase action of g-aminobutyric acid immediate
Lithium Decrease activity of receptor-linked enzyme systems 2±4 weeks (mania)
treatment after about six months. However, begins, it will take five times the half-life for the
many psychiatric disorders are persistent or concentration in plasma to reach a steady state.
highly recurrent, and here drug treatment may This can be important when planning treat-
need to be continued in the longer term. ment. For example, monoamine oxidase in-
Where circumstances are favorable it is often hibitors (MAOIs) should not be given with
worthwhile trying to discontinue drug treat- selective serotonin reuptake inhibitors (SSRIs)
ment, or at least lower the dose, while the patient because of the danger of drug interaction (see
is carefully monitored. In general, psychotropic Section 6.06.7.4.5). If, for example, a patient is
drugs should not be discontinued suddenly taking sertraline which has an elimination half-
because withdrawal symptoms may result. life of about 26 hours, it will be important to
These are seen particularly with anxiolytic leave at least five times the half-life (a week is
and antidepressant drugs. In addition, abrupt recommended) before starting MAOI treat-
discontinuation of medication can sometimes ment. When sertraline treatment begins, the
result in ªreboundº illness. For example, sudden plasma concentrations will continue to rise for
withdrawal of lithium in patients with bipolar about a week before reaching steady state.
disorder confers a risk of mania of about 50% Most psychotropic drugs have fairly long
over the next six weeks (Goodwin, 1994). This is half-lives and once or twice daily dosing is
substantially greater than that which would be sufficient. This aids compliance. Some anti-
expected from the natural history of the illness. psychotic preparations are made in the form of
long-acting intramuscular preparations. These
depot injections may need only to be given only
6.06.1.3 Pharmacokinetics of Psychotropic once or twice monthly, which again has
Drugs advantages in terms of compliance for some
patients.
Before psychotropic drugs can produce their
effects they need to reach the brain in adequate
amounts. This depends on how well they are 6.06.1.4 Prescribing Psychotropic Drugs
absorbed from the gastrointestinal tract into the
blood stream and their ability to cross the It is good practice to use well-tried drugs with
blood±brain barrier. Subsequently, drugs are therapeutic actions and side effects that are
broken down or metabolized in the liver and clearly understood. When a drug is prescribed it
then eliminated from the body in the urine by is necessary to determine the dose, the interval
the kidney. Patients with liver or kidney disease between doses and the likely duration of
can have exaggerated effects from small doses of treatment. Until a clinician is thoroughly
drugs. familiar with a drug it is important to consult
Plasma concentrations of drugs throughout the manufacturer's literature or other appro-
the day vary, rising immediately after each dose priate reference to decide the dosing schedule.
and falling at a rate that differs between Particular care should be taken to assess the
individual drugs and to some extent between possibility of drug interaction because many
individual people. However, this rate of decline patients will be taking more than one kind of
influences how long the drug persists in the body. medicine.
The concept of plasma half-life is useful here. Before providing a prescription the clinician
The half-life of a drug in plasma is the time should explain what effects are likely to be
taken for its concentration to fall by a half, once expected on first taking the drug, for example,
dosing has ceased. With most psychotropic drowsiness or dry mouth with a tricyclic
drugs, the amount eliminated over time is antidepressant. They should also explain how
proportional to plasma concentration and in long it will be before therapeutic effects will
this case it will take approximately five times the appear and what signs a patient should look for.
half-life for the drug to be eliminated from Many patients do not take their prescribed
plasma. Equally, when dosing with a drug medication either because they do not perceive
Anxiolytic Drugs 139
the need to take it or have fears about the psychiatric disorders and how they may be
possible consequences if they do. Time spent in combined with psychological methods of
discussing patient's concerns is well spent and is treatment.
likely to improve compliance with medication.
Written instructions (which are now often
6.06.3 ANXIOLYTIC DRUGS
provided as inserts to drug packaging) can be
a valuable adjunct. Anxiolytic drugs are indicated in the treat-
There are special problems about prescribing ment of anxiety disorders. It must be remem-
in pregnancy because of the risk that drugs bered, however, that the classification of anxiety
might produce adverse effects on fetal devel- disorders in the Diagnostic and statistical
opment (teratogenesis). Withdrawal symptoms manual of mental disorders (4th ed., DSM-IV)
in the new-born may also occur. Where and the International classification of diseases
possible, therefore, psychotropic drugs should (10th ed., ICD-10) subsumes a number of
not be prescribed to women who are pregnant or different disorders, some of which have a
who are considering becoming pregnant. Where distinct drug response. For example, although
drug treatment is strongly indicated, for benzodiazepines are effective in generalized
example, in a psychotic illness or with severe anxiety disorder and to some extent in panic
depression, a careful clinical risk benefit disorder, they are not useful in the treatment of
assessment should be made and discussed with obsessive compulsive disorder (Jenike, 1992).
the patient. It is usually possible to select Anxiolytic drugs are prescribed widely and
preparations that appear on current evidence to often inappropriately. There is evidence, how-
be unlikely to produce terratogenic effects. ever, that this trend may be subsiding (Tyrer,
1997). To some extent this may reflect substitu-
tion of antidepressant drugs for benzodiaze-
6.06.2 CLASSIFICATION OF DRUGS pines, since the former are effective in the
USED IN PSYCHIATRY treatment of anxiety disorders and may be less
likely to cause dependence.
Psychotropic drugs are those whose main
clinical effect is to produce a change in the
psychological state. Psychotropic drugs used in 6.06.3.1 Benzodiazepines
psychiatry are conventionally divided into 6.06.3.1.1 Pharmacology
different classes, but the therapeutic actions
Benzodiazepines are anxiolytic, sedative, and
of particular compounds are not confined to
in larger doses hypnotic. They also have muscle
one diagnostic category. For example, SSRIs
relaxant and anticonvulsant properties. Their
are classified as antidepressants and are effec-
pharmacological actions are mediated through
tive in the treatment of major depression, but
specific receptor sites, located in a supramole-
they also produce useful therapeutic effects in
cular complex with g-aminobutyric acid
panic disorder, obsessive compulsive disorder
(GABA) receptors. Benzodiazepines enhance
and social phobia (Cowen, 1997). This breadth
GABA neurotransmission, thereby altering
of effect does not mean that the latter
indirectly the activity of many other neuro-
syndromes are forms of depression. It merely
transmitters, for example, noradrenaline and
emphasizes that the neuropsychological con-
serotonin (Stahl, 1996).
sequences of facilitating brain serotonin func-
tion may provide beneficial effects in a variety of
6.06.3.1.2 Compounds available
psychiatric disorders.
Although there is considerable understand- Many different benzodiazepines are avail-
ing of the pharmacological actions of psycho- able. They differ both in the potency with which
tropic drugs, little is known about the they interact with a benzodiazepine receptor,
neuropsychological consequences of these and in their plasma half-life. In general, high
pharmacological actions and about the ways potency benzodiazepines and those with short
in which neuropsychological changes are trans- half-lives are more likely to be associated with
lated into clinical benefit in different diagnostic dependence and withdrawal. Benzodiazepines
syndromes. At present, therefore, the best plan with short half-lives (less than 12 hours) include
is to classify drugs according to their major lorazepam and temazepam. Because of pro-
therapeutic use but to bear in mind therapeutic blems with dependence, long-acting compounds
effects of different classes of drugs may overlap are preferable for the management of anxiety,
(Table 3). even if such treatment is to be given intermit-
These groups of drugs will be discussed in tently and on an as-required basis. The long-
turn. Subsequently, general advice will be given acting benzodiazepines include drugs such as
about the use of psychotropic drugs in different diazepam and chlordiazepoxide.
Table 3 Classification of clinical psychotropic drugs.
Class of drug Examples of classes Indications
Antipsychotic Phenothiazines, Acute treatment of schizophrenia and mania;

Butyrophenones, prophylaxis of schizophrenia
Dibenzazepine
Antidepressant Tricyclic antidepressants Major depression (acute treatment and prophylaxis);
MAOIs anxiety disorders; obsessive-compulsive disorder
SSRIs (SSRIs)
SNRIs
Mood Lithium, Acute treatment of mania; prophylaxis of recurrent
stabilizer Carbamazepine, mood disorder
Valproate
Anxiolytic Benzodiazepines, Generalized anxiety disorder
azapirones (buspirone)
Hypnotic Benzodiazepines, Insomnia
Cyclopyrrolones (zopiclone),
imidazopyridine (zolpidem)
Diazepam is rapidly absorbed, and can be drug and the dosage, and has been estimated at
used both for continuous treatment of anxiety between 5% and 50% among patients taking the
and for treatment as required. Alprazolam, a drugs for more than six months. Although
high-potency and long-acting benzodiazepine, escalation during treatment is unusual, pro-
is used widely outside the UK for the treatment blems can appear when patients try to dis-
of panic disorder. This therapeutic efficacy is continue their medication, whereupon a
not confined to alprazolam, however, because withdrawal syndrome becomes apparent. This
equivalent doses of other high-potency agents, is characterized by anxiety, insomnia, nausea,
such as clonazepam, are also effective (Nutt & and tremor, together with perceptual distur-
Bell, 1997). Flumazenil is a benzodiazepine bances (Pertursson & Lader, 1984; Tyrer, 1997).
receptor antagonist. This drug produces little Withdrawal symptoms generally begin within
pharmacological effect by itself but blocks the 2±3 days of stopping a short-acting benzodia-
action of other benzodiazepines (Nutt, Cowen, zepine, or within about seven days of stopping a
& Little, 1982). It is therefore used to reverse longer-acting one. The symptoms generally last
acute toxicity of benzodiazepines, but carries a for 3±10 days. If benzodiazepines have been
risk of provoking withdrawal symptoms in taken for a long time, it is best to withdraw them
chronic users. gradually over several weeks under supervision
(Tyrer, Rutherford, & Huggett, 1981). Despite
this, a few patients either cannot discontinue
6.06.3.1.3 Adverse effects their benzodiazepines satisfactorily or are
Benzodiazepines are generally well tolerated. troubled by persistent long-standing withdrawal
When they are given as anxiolytics, their main symptoms for long periods of time after the
side effects are due to sedative properties that drugs have been discontinued.
can lead to ataxia and drowsiness. A degree of
cognitive impairment may be detectable, which 6.06.3.2 Azapirones
is obviously a matter of concern when people are
driving or operating machinery. The adverse The only drug in this class currently marketed
effects of benzodiazepines are potentiated by for the treatment of anxiety is buspirone. This
alcohol. Although in some circumstances ben- drug has no affinity for benzodiazepine recep-
zodiazepines may lower tension and aggression, tors but stimulates a subtype of serotonin
in some people they can increase aggressive receptor called the serotonin-1A receptor. This
behavior, probably through disinhibition (Cow- receptor is found in high concentration in the
drey & Gardner, 1988). They should therefore raphe nuclei in the brain stem, where it regulates
be prescribed only with great caution to those the firing of serotonin cell bodies. Administra-
with a previous history of impulsive aggressive tion of buspirone lowers the firing rate of
behavior. serotonin neurones and thereby decreases
It is now generally agreed that physical serotonin neurotransmission in certain brain
dependence develops after prolonged use of regions. This action may be the basis of its
benzodiazepines. The frequency depends on the anxiolytic effects (Yocca, 1990).
Antipsychotic Drugs 141
Buspirone is different to benzodiazepines in are widely used as hypnotics. Most hypnotics

that its anxiolytic effects take several days to in common use act at the benzodiazepine
develop, whereas those of benzodiazepines are GABA receptor complex; this includes more
apparent very quickly. Its side effect profile also recently introduced compounds such as zolpi-
differs; for example, it is associated with light- dem and zopiclone. Occasionally, low-dose
headedness, nervousness, and headache early in tricyclic antidepressants are used as hypnotics
treatment. There is little evidence that tolerance because of their sedating effects. Similarly,
and dependence occur during buspirone use, sedating antihistamines such as chlophenira-
although such judgment must always be made mine have been employed to promote sleep.
with circumspection. There is some evidence Hypnotic drugs have two major problems;
that patients who have previously responded to first, the development of tolerance, with re-
treatment with benzodiazepines do not respond bound insomnia when medication is discon-
well to buspirone. Buspirone cannot be used to tinued; and second, hangover effects that can
treat benzodiazepine withdrawal. Although compromise psychological performance the
buspirone appears to be effective in the next day.
treatment of generalized anxiety disorder,
current evidence does not suggest that it confers 6.06.4.1 Compounds Available
benefit in the treatment of panic disorder
(Cowen, 1992). The most commonly used hypnotics are
benzodiazepines with short half-lives, such as
temazepam and lormetazepam. However, there
6.06.3.3 Other Drugs Used to Treat Anxiety is increasing use of nonbenzodiazepine drugs
6.06.3.3.1 Antidepressant drugs such as zopiclone, a cyclopyrrolone, and
zolpidem, an imidazopyridine. With these
Antidepressants usually ameliorate the anxi- shorter-acting compounds daytime hangover
ety that accompanies depressive disorders. In is less common but is still experienced by some
addition, tricyclic antidepressants and trazo- patients.
done have been shown to be as effective as Both zopiclone and zolpidem bind to a site
benzodiazepines in the management of general- close to the benzodiazepine receptor, thereby
ized anxiety and panic disorder (Rickels, facilitating brain GABA function. Zopiclone
Downing, Schweizer, & Hassman, 1993). SSRIs and zolpidem produce fewer changes in sleep
and MAOIs are also effective in the treatment of architecture than benzodiazepines, and are also
panic disorder, but the selective noradrenaline claimed to be less liable to produce tolerance
reuptake inhibitor, maprotiline, is not (Den and dependence (Langtry & Benfield, 1990).
Boer & Westenberg, 1988). This has not yet been fully substantiated. The
most common side effect of zopiclone is a bitter
6.06.3.3.2 Antipsychotic drugs after-taste following injection, but behavioral
disturbances including confusion, amnesia, and
These drugs are sometimes prescribed for their depressed mood have been reported. Zolpidem
anxiolytic effect. They are not more effective has also been associated with behavioral
than benzodiazepines, but may have a place in disturbances but more commonly causes nausea
the group of patients who have become irritable and dizziness.
and disinhibited with benzodiazepines. Other hypnotic drugs include chloral hydrate
and chlormethiazole. The latter has a short half-
6.06.3.3.3 b-Adrenoceptor antagonists life and is commonly used to facilitate sleep in
These include drugs such as propanolol which the elderly. In addition, in some countries,
are used to treat hypertension. Such drugs relieve chlormethiazole is used to prevent withdrawal
some of the autonomic (peripheral) symptoms of symptoms in patients dependent on alcohol.
anxiety, such as tachycardia and tremor, by For this reason it is sometimes thought,
blocking peripheral b-adrenoceptors. In general mistakenly, to be a suitable hypnotic for
they are not particularly helpful in the treatment alcoholic patients. In fact, chlormethiazole
of patients with anxiety disorders, but can be has barbiturate-like actions and can cause
helpful in otherwise healthy subjects who respiratory depression when combined with
develop marked autonomic symptoms coupled alcohol or in overdose.
to performance anxiety.
6.06.5 ANTIPSYCHOTIC DRUGS
6.06.4 HYPNOTIC DRUGS
This term is applied to drugs that reduce
Hypnotic drugs are used to improve sleep. psychomotor overactivity and diminish symp-
The benzodiazepine drugs described previously toms of psychosis. Alternative terms for these
drugs are neuroleptic and major tranquilizer. and tend to lower blood pressure. They are,
None of these names is wholly satisfactory. however, less likely to cause movement dis-
Neuroleptic refers to the side effects rather than orders than nonsedating phenothiazines, such
to the therapeutic effects of the drugs, and major as trifluoperazine and fluphenazine. The phar-
tranquilizer does not refer to the most important macological profile of the thioxanthenes, such
clinical action, that of ameliorating the symp- as flupenthixol and clopenthixol, resembles the
toms of psychosis. Therefore, the term anti- nonsedating phenothiazines and the same is true
psychotic drug is preferred here. of the butyrophenone, haloperidol.
The main therapeutic uses of antipsychotic A number of typical antipsychotic drugs (the
drugs are to reduce hallucinations, delusions, decanoates of haloperidol, fluphenazine, flu-
agitation, and psychomotor excitement in penthixol and zuclopenthixol) are available as
schizophrenia, mania, or psychosis secondary long-acting intramuscular depot preparations,
to a medical condition. The drugs are also used given at intervals of 2±4 weeks. For many
prophylactically to prevent relapse of schizo- patients continued medication is the only way to
phrenia and occasionally mania (Gelder, Gath, prevent psychotic relapse. In some subjects
Mayou, & Cowen, 1996). compliance with medication is better if they will
accept a long-acting intramuscular preparation.
Another intramuscular preparation is zuclo-
6.06.5.1 Pharmacology penthixol acetate whose action lasts for 1±2
Antipsychotic drugs share the property of days. This preparation can be useful in an
blocking brain dopamine receptors. Dopamine acutely psychotic patient where antipsychotic
receptors are of several biochemical subtypes, medication is needed but where oral drug
but most antipsychotic drugs bind strongly to administration is ineffective or not possible.
dopamine-D2 receptors, and this action appears The disadvantage of this approach is that it is
to account both for their antipsychotic activity not easily possible to titrate the dosage of
and their propensity to cause movement medication for an individual patient (Royal
disorders. College of Psychiatrists, 1993).
Actions at other neurotransmitter receptors
may offset the liability of D2 receptor antago- 6.06.5.2.2 Atypical antipsychotic drugs
nists to produce movement disorders. For
example, thioridazine is a potent antagonist at These include a number of compounds that
muscarinic cholinergic receptors, and anti- differ strikingly in their structure and pharma-
cholinergic drugs are known to possess anti- cological properties. Sulpiride is a D2 receptor
Parkinsonian effects. This might account for blocker, but it appears to act more selectively on
the diminished liability of thioridazine to cause D2 receptors on mesolimbic and mesocortical
movement disorders. Similarly, the lack of regions than on those in the basal ganglia. This
movement disorders associated with risperi- might account for its reduced liability to cause
done and olanzapine has been attributed to the extrapyramidal side effects. In contrast, risper-
ability of these drugs to block serotonin2 idone is a potent D2 receptor antagonist but is
receptors as well as D2 receptors (see Stahl, even more potent at blocking serotonin2
1996). receptors. Concomitant serotonin2 receptor
blockade is believed to attenuate the movement
disorders caused by unnopposed D2 receptor
6.06.5.2 Compounds Available antagonism (Livingston, 1994).
Olanzapine and sertindole are also serotonin2
A large number of antipsychotic compounds receptor antagonists but have less effect than
have been developed. The main distinction of risperidone on D2 receptors. Both these factors
clinical utility is into typical and atypical may account for their decreased liability to
antipsychotics. Atypical antipsychotics are so cause movement disorders (Gerlach & Peacock,
called because they have a decreased likelihood 1995; Reus, 1997). In addition, it has been
to cause extrapyramidal side effects or move- claimed that risperidone, olanzepine, and
ment disorders. sertindole are more effective than typical
antipsychotics, particularly having some activ-
ity against so-called negative symptoms of
6.06.5.2.1 Typical antipsychotics
schizophrenia, which are difficult to treat
These drugs have comparable efficacy in the pharmacologically (Marder & Meibach, 1994;
treatment of psychosis but different side effect Tollefson & Sanger, 1997). These claims are
profiles because of their other pharmacological currently being tested but clinically risperidone
properties. For example, phenothiazines such as and olanzepine are being used increasingly in
chlorpromazine and thioridazine are sedating preference to typical antipsychotic drugs.
Antipsychotic Drugs 143
Clozapine is an important drug because it is such as propranolol, and short-term benzodia-

the only drug with established efficacy in zepine administration has also been employed.
patients who are resistant to other antipsychotic The Parkinsonian syndrome caused by anti-
treatments (Kane, Honigfeld, Singer, & Melt- psychotic drugs presents with the usual clinical
zer, 1988). Clozapine has complex pharmacol- triad of akinesia, tremor, and muscular rigidity.
ogy with weak binding to dopamine-D2 These symptoms can be controlled by lowering
receptors but strong antagonist properties at the dose of the antipsychotic drug or with
a variety of serotonin and noradrenergic anticholinergic agents (see below).
receptors. Because of a rare but serious adverse The last syndrome, tardive dyskinesia, is
effect on white blood cells, clozapine can be used particularly serious because, unlike the other
only with special monitoring (see below). extrapyramidal effects, it does not always
recover when antipsychotic drugs are stopped.
It is usually characterized by chewing and
6.06.5.3 Adverse Effects sucking movements of the lips and jaw, but can
involve limbs and occasionally the whole body.
6.06.5.3.1 Movement disorders
Although this syndrome is seen occasionally
Probably the most troublesome side effect of among patients who have not taken antipsy-
antipsychotic drugs, particularly typical anti- chotic drugs, clinical observations suggest it is
psychotics, are movement disorders, which are a much more common in those who have received
consequence of D2 receptor blockade in the antipsychotic agents for extended periods of
basal ganglia. At least four different kinds of time. Estimates of the frequency of the
movement disorder are recognized: acute dys- syndrome vary in different series, but it seems
tonia, akathisia (a Parkinsonian syndrome), to develop in 20±30% of patients with schizo-
and tardive dyskinesia (Table 4). phrenia treated with long-term antipsychotic
Acute dystonia occurs soon after treatment drugs (Jeste & Caligiuri, 1993). Whatever the
begins, especially in young men. It is observed exact incidence, the risk of this syndrome should
most often with drugs such as haloperidol and be a deterrent to the long-term prescription of
trifluoperazine. The main features are caused by antipsychotic drugs unless clearly indicated.
acute contraction of muscle groups, resulting in Many treatments for tardive dyskinesia have
torticollis (neck twisting), tongue protrusion, been tried but none is universally effective. The
grimacing and oculogyric crisis (rolling upward antipsychotic drug should be stopped if the state
of the eyes). These symptoms are distressing and of the psychiatric illness allows this. About 50%
alarming for patients, and can be controlled by of cases may then remit. Where this in not
anticholinergic drugs, such as benztropine or a possible, increasing the dose of antipsychotic
benzodiazepine. drug may produce some suppression of move-
Akathisia is an unpleasant feeling of physical ment symptoms but this relief is usually
restlessness, with a compelling need to move. temporary. Sulpiride, however, may provide
Patients are usually very distressed by akathisia rather more sustained benefit with few adverse
and can present in a state of severe agitation. It effects. Interestingly, treatment with vitamin E
usually occurs in the first few weeks of treatment has been found useful in some studies (Jeste &
with antipsychotic drugs but may only begin Caligiuri, 1993).
after several months. Akathisia is not reliably
treated by anticholinergic drugs, but may
6.06.5.3.2 Autonomic and endocrine effects
disappear when the dose of the antipsychotic
agent is reduced. Some cases are helped by Several of the antipsychotic drugs, particu-
treatment with b-adrenoceptor antagonists, larly phenothiazines, such as chlorpromazine
Table 4 Some unwanted effects of antipsychotic drugs.
Effect Symptoms
Movement disorders Acute dystonia, akathisia, parkinsonism,

tardive dyskinesia
Autonomic and endocrine effects Dry mouth, constipation, urinary hesitancy,
blurred vision, sedation, postural
hypotension, hypothermia, amenorrhoea,
galactorrhoea, decreased libido
Other Cardiac arrhythmias, weight gain,
agranulocytosis (clozapine)
and thioridazine, are antagonists at muscarinic antipsychotic treatment is reinstated, and it is

cholinergic receptors. This leads to dry mouth, prudent to start treatment cautiously with an
urinary hesitancy and retention, constipation, oral low potency drug such as thioridazine.
reduced sweating, blurred vision, and rarely the
precipitation of glaucoma.
6.06.5.3.4 Other adverse effects
Phenothiazines, and risperidone also have
strong antagonist activity at a1-adrenoceptors. A rare adverse effect, but one which is of
This leads to sedation, hypotension and sexual particular concern, is the development of
dysfunction. Antipsychotic drugs that block cardiac arrhythmias. Subclinical electrocardio-
histaminic and some subtypes of serotonin gram (ECG) changes are not uncommon and
receptors can cause troublesome weight gain. usually take the form of prolongation of the QT
This can be a particular problem with chlopro- interval. This appears to be more problematic
mazine, thioridazine, clozapine, and olanzepine. with some drugs than others, for example,
Blockade of D2 receptors elevates plasma pimozide and sertindole, where the use of ECG
prolactin levels which can cause amenorrhoea monitoring has been recommended. It should
and galactorrhoea in women and loss of libido also be noted that most antipsychotic drugs
in both sexes. The atypical antipsychotic drugs, appear to lower the seizure threshold to some
with the exception of risperidone and sulpiride extent, so must be used with caution in patients
appear to have less effect on plasma prolactin. with a tendency to seizure disorder.
Typical antipsychotic drugs have not been
shown to be teratogenic, but nevertheless should
6.06.5.3.3 Neuroleptic malignant syndrome
be used cautiously in early pregnancy. There is
This rare but serious disorder occurs in a presently insufficient data on the possible
small minority of patients taking antipsychotic teratogenic effects of the atypical antipsychotic
drugs, particularly high-potency compounds. drugs.
Most reported cases have followed the use of
antipsychotic drugs for schizophrenia, but in
6.06.5.3.5 Adverse effects of clozapine
some cases the drugs were used for mania,
depressive disorder, and psychosis secondary to As noted above, the use of clozapine requires
a medical condition. The clinical picture special monitoring with regard to blood white
includes the rapid onset, over 24±72 hours, of cell count. For this reason both the hematolo-
severe motor, cognitive, and autonomic dis- gical and other adverse effects of clozapine will
orders. The prominent motor symptom is be discussed here.
generalized rigidity. The psychological symp- The use of clozapine is associated with a
toms include mutism, stupor, or fluctuating significant risk of leucopenia (about 2±3%)
levels of consciousness. Hyperpyrexia develops which can progress to agranulocytosis (Krupp
with evidence of autonomic instability in the & Barnes, 1992). Weekly blood counts for the
form of rapidly changing blood pressure, first 18 weeks of treatment and at two week
tachycardia, excessive sweating and urinary intervals thereafter are mandatory. With this
incontinence. Plasma levels of the enzyme, intensive monitoring the early detection of
creatinine phosphokinase, are increased to very leucopenia can be followed by immediate
high levels. The neuroleptic malignant syn- withdrawal of clozapine and reversal of the
drome has a significant mortality, which may be low white cell count. This procedure greatly
declining but is probably still about 10%. The reduces, but does not eliminate, the risk of
syndrome lasts for 1±2 weeks after stopping an progression to agranulocytosis. It is usually
oral neuroleptic, but may last 2±3 times longer recommended that clozapine be used as the sole
after stopping long-acting preparations. Pa- antipsychotic agent in a treatment regimen.
tients who survive usually make a complete Clearly, it is wise to avoid concomitant use of
recovery but residual movement disorders are drugs such as carbamazepine, which may also
sometimes seen (Addonizio & Susman, 1991). lower the white cell count.
The mainstay of treatment in neuroleptic Because of its relatively weak blockade of
malignant syndrome is symptomatic, with dopamine D2 receptors, clozapine is less likely
support in an intensive care unit if needed. than other antipsychotic drugs to cause extra-
No drug treatment is of definite utility. The pyramidal movement disorders. It does not
dopamine receptor agonist, bromocriptine, is increase plasma prolactin, hence galactorrhoea
often tried, but there is no definite evidence of does not occur. However, its use is associated
effectiveness. Patients who have developed with hypersalivation, drowsiness, postural hy-
neuroleptic malignant syndrome may need in potension, weight gain, and hyperthermia.
the future to be treated with antipsychotic Seizures may occur at higher doses. Rarely,
drugs. At least two weeks should elapse before myocarditis has been reported.
Antidepressants 145
6.06.5.4 Dosage of Antipsychotic Drugs Table 5 Daily dose of different

antipsychotic drugs required to produce
Doses of antipsychotic drugs need to be greater than 70% blockade of D2
adjusted for the individual patient and changes receptors in basal ganglia.
should be made gradually. There is a growing
trend for lower doses to be recommended. This Dose
is based in part on recent studies with positron Drug (mg)
emission tomography which have demonstrated
that adequate dopamine D2 receptor blockade Chlorpromazine 200
Thioridazine 300
can be obtained with low doses of conventional
Trifluoperazine 10
antipsychotic drugs, for example, 5 mg a day of Haloperidol 4
haloperidol (Farde, Wiesel, & Nordstrom, Flupenthixol 10
1989) (Table 5). Such doses produce an Sulpiride 800
adequate antipsychotic effect in the majority
of patients. Higher doses may cause further
Source: Farde et al. (1989).
calming but are also likely to be associated with
significant adverse effects, some of which may
be serious, for example, cardiac arrhythmias. A psychiatric practice are benzhexol, benztropine,
view of growing influence is that the combina- procyclidine, and orphenadrine. An injectable
tion of modest doses of antipsychotic drugs with preparation of biperiden is useful for the
a benzodiazepine is a safer and more effective treatment of acute dystonias.
means of producing rapid sedation than high
doses of antipsychotic drugs (Pilowsky, Ring,
Shine, Battersby, & Lader, 1992). 6.06.6.2 Adverse Effects
The association of sudden unexplained death In large doses these drugs may cause an acute
with antipsychotic drug treatment is a matter of organic syndrome, particularly in the elderly.
continuing debate. For example, it is not Their anticholinergic activity can summate with
established whether the rate of such deaths is those of antipsychotic drugs so that glaucoma
greater in patients receiving antipsychotic drugs or retention of urine in men with enlarged
than in those receiving other treatments, or prostates may be precipitated. Drowsiness, dry
whether the rate in psychiatric patients is higher mouth and constipation also occur. These
than in the general population. However, effects tend to diminish as the drug is continued.
antipsychotic drugs are known to alter cardiac Anticholinergic drugs can also exacerbate
conduction (see above), and some drugs, such as tardive dyskinesia but are probably not a
chlorpromazine, also produce hypotension. predisposing factor in its development. Antic-
Although the relationship between high doses holinergic drugs can also be abused for their
of antipsychotic drug treatment and sudden euphoriant and psychomimetic effects at high
death is not established, it is clearly prudent to doses.
use as low a dose of an antipsychotic drug as the
clinical circumstances permit (Royal College of
Psychiatrists, 1993). 6.06.7 ANTIDEPRESSANTS
Antidepressant drugs are indicated in the
6.06.6 ANTI-PARKINSONIAN DRUGS treatment of major depression and dysthymia.
Certain antidepressants are also effective in the
Although these drugs have no direct ther- treatment of anxiety disorders, and the eating
apeutic use in psychiatry, they are often disorder bulimia nervosa. Currently used anti-
required to control the extrapyramidal side depressant drugs can be divided into three main
effects of antipsychotic drugs, particulary acute classes, depending on their acute pharmacolo-
dystonia and symptoms of Parkinsonism. They gical properties. The first class consists of
are of modest benefit in akathisia and actually compounds that inhibit the reuptake of nora-
worsen tardive dyskinesia. The pharmacologi- drenaline and/or serotonin. This class includes
cal effect of these drugs is to block peripheral the tricyclic antidepressants and the SSRIs. The
and central muscarinic cholinergic receptors. second class consists of drugs that inhibit the
enzyme MAO. The third class consists of drugs
6.06.6.1 Preparations Available with complex effects on monoamine mechan-
isms, for example, mianserin and nefazodone,
Many anticholinergic drugs are available and which cannot be easily categorized under the
there is no reason for choosing one over the first two headings.
others for the treatment of neuroleptic induced In the broad range of major depression, these
movement disorders. Those most often used in drugs are of equivalent efficacy. The main
distinctions between them are in their adverse 6.06.7.2 Tricyclic Antidepressants

effects, toxicity, and cost (Table 6). These three
classes of drugs will be considered in turn after 6.06.7.2.1 Pharmacological properties
some comments on the possible mechanism of Tricyclic antidepressants have a three-ringed
action of antidepressants. structure with an attached side chain. The first
tricyclic to be introduced was imipramine, and
there have been many modifications, so that a
6.06.7.1 Mechanism of Action range of tricyclic compounds is now available.
These can broadly be divided into tertiary and
The primary pharmacological action of secondary amines, the distinction being that
reuptake inhibitors and MAOIs can be detected tertiary have a terminal methyl group on the side
within hours of the start of treatment, and yet chain, whereas the secondary amines do not. In
the antidepressant effects of drug therapy can be general, compared with the secondary amines,
delayed for a number of weeks. For example, it tertiary amines have a higher potency to block
has been suggested that 4±6 weeks should elapse the serotonin reuptake site and are stronger
before an assessment of the effect of an antagonists of noradrenaline a1-adrenoceptors
antidepressant drug can be made in an and muscarinic cholinergic receptors. There-
individual patient (Depression Guideline Panel, fore, in clinical use tertiary amines are more
1993; Quitkin et al., 1996). sedating and cause more anticholinergic side
In animal experimental studies, the acute effects than secondary amines. In the UK,
effect of antidepressants to facilitate noradrena- tertiary amines such as amitriptyline, dothiepin,
line and serotonin neurotransmission is fol- and imipramine are popular in the treatment of
lowed by numerous secondary adaptive changes depression, whereas in the USA secondary
in noradrenaline and serotonin pathways. It is amines such as desipramine and nortriptyline
thought that it is these neuroadaptive changes are more commonly used.
that lead to the clinical antidepressant effect, Antidepressant drugs also antagonize hista-
probably by further enhancing the acute mine H1 receptors, which can cause drowsiness
potentiation that antidepressant drugs produce and weight gain. Tricyclics also have quinidine-
on noradrenaline and serotonin neurotransmis- like membrane stabilizing effects. This may
sion (Blier & Montigny, 1994; Svensson & explain why they impair cardiac conduction and
Usdin, 1978). cause high toxicity in overdose.
An important action observed in animal
experimental studies following repeated admin-
istration of antidepressant drugs is a gradual 6.06.7.2.2 Adverse effects of tricyclic
desensitization of inhibitory autoreceptors on antidepressants
serotonin and noradrenaline cell bodies. These The adverse effects of tricyclic antidepres-
receptors normally have the effect of decreasing sants can, in general, be derived from their
the firing of these cells, and hence their receptor blocking properties (Table 7). As
desensitization would be expected to add to mentioned above, anticholinergic and antiadre-
the facilitation of neurotransmission produced nergic effects are common. In addition, the
by the antidepressant. Thus the clinical effects of drugs can cause tiredness and drowsiness,
antidepressant treatment may result from an although secondary amines, such as desipra-
increasing potentiation of noradrenaline and mine, can cause insomnia. Fine tremor and
serotonin neurotransmission over time. muscle twitching have been observed and like
Table 6 Side effect profiles of some antidepressant drugs.
Drug Anticholinergic Sedation Insomnia Cardiotoxic Nausea/vomiting
Amitriptyline +++ +++ 0 +++ 0

Desipramine ++ + + +++ 0
Lofepramine ++ + + 0 0
Trazodone 0 +++ 0 + ++
Nefazodone 0 + 0 0 ++
Mirtazapine 0 +++ 0 0 0
SSRIs 0 0/+ ++ 0 +++
SNRI 0 0/+ ++ 0 +++
0 = not present; +++ = strong.

Antidepressants 147
antipsychotic drugs, tricyclic antidepressants use of a single preparation to produce combined

lower the seizure threshold, which means they pharmacological effect limits prescribing flex-
must be used with caution in people predisposed ibility. Furthermore, as might be expected, the
to seizure disorders. Allergic skin rashes, D2 receptor blocking properties of amoxapine
cholestatic jaundice, and agranulocytosis, are may result in extrapyramidal disorders (Ru-
seen rarely. Weight gain and sexual dysfunction dorfer & Potter, 1980).
are more common.
Sudden withdrawal of tricyclics can produce
an abstinence syndrome, characterized by 6.06.7.2.4 Clomipramine
nausea, anxiety, sweating, and insomnia. Cur-
rent evidence does not suggest that tricyclics Clomipramine is the most potent of the
such as amitriptyline and imipramine are tricyclic antidepressants in inhibiting the re-
important human teratogens. There is less data uptake of serotonin. Probably because of this,
about other tricyclic antidepressants. unlike other tricyclic antidepressants, clomipra-
In overdose, tricyclic antidepressants promine is useful in treating the symptoms of
duce a large number of effects, of which some obsessive compulsive disorder whether or not
are extremely serious. Therefore urgent expert there is a coexisting major depression (Jenike,
treatment in a general hospital is required. The 1992). Clomipramine is also available as an
main danger comes from cardiovascular effects, intravenous infusion, but in general this form of
which include cardiac arrhythmias with ven- administration does not appear to produce
tricular fibrillation. In addition, respiratory better therapeutic effects than the oral route.
depression can occur, and the resulting hypoxia
increases the likelihood of cardiac complica-
tions. Tricyclics delay gastric emptying, and so 6.06.7.2.5 Lofepramine
gastric lavage is valuable for several hours after
the overdose. Lofepramine is a fairly selective inhibitor of
noradrenaline reuptake, and has fewer anti-
cholinergic and antihistaminic properties than
amitriptyline. It has been widely compared with
6.06.7.2.3 Amoxapine
other tricyclic antidepressants, and in general its
Some tricyclics have pharmacological prop- antidepressant efficacy is equivalent. Lofepra-
erties sufficiently distinct to be worth separate mine is not sedating; early in treatment it can be
mention. Amoxapine is a fairly selective experienced as activating, an effect which some
inhibitor of noradrenaline uptake but, unu- depressed patients find unpleasant. Similarly,
sually for a tricyclic antidepressant, produces impaired sleep does not usually improve until
significant blockade of dopamine D2 receptors. the underlying depression remits. The most
The combined effect of amoxapine to increase important feature of lofepramine is that in
noradrenaline neurotransmission and antago- overdose it is not cardiotoxic and it is therefore
nize D2 receptors has led to suggestions that this much safer than conventional tricyclic anti-
compound may be particularly useful in the depressants. Therefore lofepramine is likely to
treatment of depressive psychosis when com- be safer than other tricyclics for patients with
bined treatment with antidepressant and anti- cardiovascular disease, although caution is still
psychotic drugs is often required. However, the required (Lancaster & Gonzalez, 1990).
Table 7 Some adverse effects of tricyclic antidepressants.
Pharmacological action Adverse effect
Anticholinergic Dry mouth, tachycardia, blurred vision,

glaucoma, constipation, urinary
retention, cognitive impairment
Antiadrenergic Drowsiness, postural hypotension, sexual
dysfunction
Histamine H1 receptor blockade drowsiness, weight gain
Other Cardiac conduction defects, cardiac
arrhythmias, epileptic seizures, (all
common in overdose), rash, oedema,
sweating, low white cell count (rare)
6.06.7.2.6 Maprotiline superior to placebo and are generally as effective

as tricyclics antidepressants in the treatment of
Maprotiline is often referred to as a quad-
major depression. Most comparative studies
ricyclic antidepressant because the tricyclic
have been of moderately depressed outpatients,
nucleus is supplemented by an ethylene bridge
and there has been concern that SSRIs may be
across the middle ring. It is the most selective
less effective than conventional tricyclic anti-
noradrenaline uptake inhibitor of the tricyclic
depressants for more severely depressed pa-
antidepressants currently available, but has
tients. This is based to some extent on the work
moderate antihistaminic properties and rather
of the Danish University Antidepressant Group
less anticholinergic effects than imipramine. It
(1990), who found that the tricyclic clomipra-
appears as effective as reference tricyclics. The
mine is significantly more effective than either
use of maprotiline at doses above 200 mg daily
paroxetine or citalopram in depressed inpati-
have been associated with a higher incidence of
ents. In addition, more recent meta-analyses
seizures than is usual during tricyclic treatment.
have suggested that SSRIs may be slightly less
Therefore a dose range of 75±150 mg daily has
effective than drugs that potently block the
been recommended, and the coprescription of
reuptake of both serotonin and noradrenaline.
other drugs that may lower the seizure thresh-
This categorization includes clomipramine and
old, such as phenothiazines, should be ap-
the new antidepressant, venlafaxine (Anderson,
proached with caution. Maprotiline has effects
1997) (see below).
on the heart that are similar to those of
conventional tricyclics, and in overdose it is at
least as toxic (Rudorfer & Potter, 1989).
6.06.7.3.3 Unwanted effects of SSRIs
6.06.7.3 Selective Serotonin Reuptake Inhibitors The SSRIs have a different side effect profile
to tricyclic antidepressants and are somewhat
6.06.7.3.1 Pharmacological properties
better tolerated at therapeutic dosage (Table 8).
Five SSRIs, citalopram, fluoxetine, fluvox- In meta-analyses against conventional tricyclic
amine, paroxetine, and sertraline, are available antidepressants the drop-out rate due to adverse
at present for clinical use in the UK. SSRIs are a effects with SSRIs is about 25% less. Whether
structurally diverse group, but they all inhibit this confers significant cost benefit is contro-
the reuptake of serotonin with a high potency versial.
and selectivity. None of them has an appreciable The SSRIs are less cardiotoxic than tricyclic
affinity for the noradrenaline uptake site, and antidepressants and are safer in overdose. They
present data suggest that they have a low affinity also lack anticholinergic effects and are less
for other monoamine neurotransmitter recep- sedating. Their adverse effect profile consists
tors (Stahl, 1996). mainly of gastrointestinal symptoms and central
nervous system effects. Sexual dysfunction is
also common, occurring in up to about 25% of
6.06.7.3.2 Efficacy in depression
people. A rare but problematic side effect, more
The SSRIs have been extensively compared frequent in the elderly, is a low sodium state.
with placebo and with reference tricyclic They can rarely cause movement disorders.
antidepressants. The SSRIs are all clearly Discontinuation of paroxetine and sertraline
Table 8 Some side effects of SSRIs.
Effect Symptoms
Gastrointestinal Common: nausea, appetite loss, dry mouth,

diarrhea, constipation, dyspepsia
Uncommon: vomiting, weight loss
Central nervous system Common: headache, insomnia, dizziness,
anxiety, fatigue, tremor, somnolence
Uncommon: extrapyramidal reaction,
seizures
Other Common: sweating, delayed orgasm,
anorgasmia
Uncommon: rash, pharyngitis, dyspnoea,
serum sickness, hyponatremia, alopecia
Antidepressants 149
has been associated with a withdrawal syn- ability to inhibit MAO with an amphetamine-
drome consisting of nausea, irritability, im- like stimulating effect. There are more reports of
paired sleep and ataxia (Cowen, 1996). adverse drug and food reactions with tranylcy-
It is not clear whether SSRIs are human promine than other MAOIs, so it should be
teratogens. Fluoxetine may increase rates of prescribed with particular caution.
premature delivery and perhaps minor fetal Moclobemide is the most recently developed
abnormalties, but this is controversial (Cham- MAOI to be marketed. It differs from the other
bers, Johnson, & Dick, 1996; Robert, 1996). compounds in selectively binding to MAO-A,
which it inhibits in a reversible way. This results
in a lack of significant interactions with food-
6.06.7.4 Monoamine Oxidase Inhibitors stuffs and a quick offset of action (see below).
MAOIs were introduced just before the
tricyclic antidepressants, but their use has been 6.06.7.4.3 Efficacy of MAOIs in depression
less widespread because of both troublesome For many years MAOIs were in relative
interactions with foods and drugs and uncer- disuse because several studies, in particular a
tainty about their therapeutic efficacy. Recent large controlled trial by the Medical Research
controlled studies have shown that in adequate Council, found them no better than placebo in
doses MAOIs are useful antidepressants, often the treatment of depressive disorders (Clinical
producing clinical benefit in depressed patients Psychiatry Committee, 1965). It seems likely
who have not responded to other medications that the doses of MAOIs were too low in these
or electroconvulsive therapy (ECT). In addi- early investigations; in the Medical Research
tion, MAOIs can be useful in refractory anxiety Council study the maximum dose of phenelzine
states (Nutt & Glue, 1989; Paykel, 1990). These was 45 mg daily as against the current practice
beneficial effects have to be weighed against the of doses up to 90 mg daily if side effects permit.
need to adhere to strict dietary and drug In this wider dose range MAOIs are superior to
restrictions in order to avoid reactions with placebo and generally equivalent to tricyclic
tyramine and other sympathomimetic agents. antidepressants in their therapeutic activity
In practice this means that MAOIs are very (Paykel, 1990).
rarely used as first-line treatment. It remains to
be seen whether this approach will be altered by
the recent availability of MAOIs, such as 6.06.7.4.4 Unwanted effects
moclobemide, that do not potentiate tyramine. MAOIs have numerous unwanted effects
(Table 9). In clinical practice the main problems
6.06.7.4.1 Pharmacology are insomnia, weight gain, and postural hypo-
tension. Ankle edema is also not uncommon.
The MAOIs inactivate enzymes that oxidize Phenelzine and isocarboxazid have been asso-
noradrenaline, serotonin, tyramine, and other ciated with hepatocellular jaundice. There are
amines that are widely distributed in the body as little data on the possible teratogenicity of
transmitters, or are taken in food and drink or MAOIs in humans.
as drugs. Monoamine oxidase (MAO) exists in a
number of forms that differ in their substrate
and inhibitor specificities. From the point of 6.06.7.4.5 Interactions with foodstuffs and drugs
view of psychotropic drug treatment it is Some foods contain tyramine, a substance
important to recognize that there are two forms that is normally inactivated by MAO in the liver
of MAO (type A and type B), encoded by and gut wall. When MAO is inhibited, tyramine
separate genes. In general, MAO-A metabolizes is not broken down and is free to exert its
intraneuronal noradrenaline and serotonin, hypertensive effects. These effects are due to
whereas both MAO-A and MAO-B metabolize release of noradrenaline with a consequent
dopamine and tyramine. elevation in blood pressure. This may reach
dangerous levels and may occasionally result in
cerebrovascular accident. Important early
6.06.7.4.2 Compounds available
symptoms of such a crisis include a severe
Phenelzine is the most widely used and widely and usually throbbing headache.
studied compound. Isocarboxazid is reported to There have been reports of many foods being
have fewer side effects than phenelzine and can implicated in hypertensive reactions with
be useful for patients who respond to the latter MAOIs, but many of these have cited single
drug but suffer from its side effects of hypoten- cases and hence are of uncertain validity.
sion or sleep disorder. Tranylcypromine differs Another complication is that the tyramine
from the other compounds in combining the content of a particular food item may vary, as
Table 9 Adverse effects of MAOIs.
Effect Symptoms
Central nervous system Insomnia, drowsiness, agitation, headache,

fatigue, weakness, tremor, mania,
confusion
Autonomic Blurred vision, difficulty passing urine,
sweating, dry mouth, postural
hypotension, constipation
Other Sexual dysfunction, weight gain, peripheral
neuropathy (rare), edema, rashes,
hepatocellular toxicity (rare), leucopenia
(rare)
may the susceptibility of an individual patient to 6.06.7.4.6 Moclobemide

a hypertensive reaction. If a forbidden food has
In its freedom from tyramine reactions, the
been consumed on one occasion without
reversible type A MAOI, moclobemide, has a
adverse effects, this does not preclude a future
clear advantage over conventional MAOIs
reaction. It has been concluded that the
(Simpson & De Leon, 1989). As with all new
following foods and drinks should be avoided
antidepressants, however, the therapeutic effi-
(Davidson, 1992):
cacy of moclobemide, particularly in severely ill
(i) all cheeses except cream, cottage, and
patients is not as well established as that of
ricotta cheeses;
phenelzine or tranylcypromine. Moreover, a
(ii) red wine, sherry, beer, and liquors;
recent meta-analysis suggested that it might be
(iii) pickled or smoked fish;
somewhat less effective than clomipramine
(iv) brewer's yeast products, for example,
and imipramine in depressed inpatients
Marmite, Bovril, and some packet soups;
(Angst, Amrein, & Stabl, 1995).
(v) broad bean pods;
Moclobemide is better tolerated than con-
(vi) beef or chicken liver;
ventional MAOIs but can cause insomnia and
(vii) fermented sausage, for example, pepper-
nausea. Caution still has to be exercised when
oni, salami; and
moclobemide is coprescribed with other drugs.
(viii) unfresh, overripe, or aged food, for
It is recommended that it should not be
example, pheasant, venison, unfresh dairy pro-
prescribed with SSRIs or clomipramine because
ducts.
of the risk of serotonin syndrome (see above).
Despite this list, case reports suggest that
As for the irreversible MAOIs, moclobemide
cheese is the food most often incriminated in
may react adversely with opiates and noradre-
serious adverse reactions. Hypertensive reac-
naline potentiating drugs.
tions should be treated with parenteral admin-
istration of an a1-adrenoceptor antagonist, such
as phentolamine. Chlorpromazine can be used if 6.06.7.5 Other Antidepressant Drugs
the latter is not available. Oral nifedipine may
also be useful. Whatever treatment is given, Under this heading are discussed drugs whose
blood pressure must be monitored carefully. mechanism of action cannot be easily grouped
A number of drugs cause serious interactions with tricyclic antidepressants, SSRIs, or
with MAOIs. In particular, drugs that increase MAOIs. These drugs also have differing
brain serotonin function such as the SSRIs and adverse-effect profiles. They are therefore
clomipramine can cause a fatal neurotoxicity discussed individually below.
syndrome (Sternbach, 1991). In general medi-
cine coadministration of opiate analgesics,
6.06.7.5.1 Mianserin
particularly pethidine, can produce a similar
effect. Finally, drugs that potentiate noradrena- Mianserin is a quadricyclic compound with
line can cause serious hypertensive reactions. complex pharmacological actions. It has weak
The importance of this is that such compounds noradrenaline reuptake inhibiting effects, and is
are often present in ªover-the-counterº cold and a fairly potent antagonist at a number of
flu remedies. Patients receiving MAOI treat- neurotransmitter receptors, including seroto-
ment must be warned not to take any other nin2, serotonin3, and noradrenergic a1- and a2-
medication until its safety with MAOIs has been adrenoceptors. It is not a muscarinic cholinergic
specifically checked. antagonist and is not cardiotoxic.
Antidepressants 151
Controlled trials have shown that mianserin depressed inpatients is not as well established
is superior to placebo in the management of (Rudorfer & Potter, 1998)
depression, and comparative studies against The major unwanted effect of trazodone is
imipramine and clomipramine have shown no excessive sedation, which can result in signifi-
difference in effect. These studies are difficult to cant cognitive impairment. Nausea and dizzi-
assess because of the wide range of doses that ness are also reported, particularly if the drug is
have been used. Many early studies of mianserin taken on an empty stomach. The a1-adreno-
used doses of 30±60 mg daily, whereas much ceptor antagonist properties of trazodone may
higher doses of up to 200 mg daily have lower blood pressure to some extent, and
sometimes been advocated for inpatients (Mon- postural hypotension has been reported. Tra-
tgomery, Bullock, & Pinder, 1991). zodone is less cardiotoxic than conventional
The main adverse effects of mianserin are tricyclics, but there are reports that cardiac
drowsiness and dizziness. Significant cognitive arrhythmias may be worsened in patients with
impairment is more likely with mianserin than cardiac disease. Nevertheless, trazodone is
with SSRIs, and weight gain is a common much less toxic in overdose than tricyclic
problem. The most serious adverse effect of antidepressants. A serious side effect of trazo-
mianserin is a lowering of the white cell count, done is priapism. This reaction is seen rarely
and fatal agranulocytosis has been reported. It (about 1 in 6000 male patients). It can cause
is recommended that a blood count be considerable problems, requiring the local
obtained before starting mianserin treatment, injection of noradrenaline agonists or even
and that the white cell count be monitored surgical treatment (Rudorfer & Potter, 1989).
monthly for three months after treatment has
started. 6.06.7.5.4 Nefazodone
Nefazodone is related to trazodone but lacks
6.06.7.5.2 Mirtazapine
a1-adrenoceptor antagonist properties and is
Mirtazapine is a new antidepressant which is therefore less sedating. Like trazodone it has
structurally related to mianserin. Its pharmaco- mild serotonin reuptake blocking properties,
logical properties are similar but its noradre- and is metabolized to the serotonin receptor
nergic a1-adrenoceptor blockade is less potent agonist mCPP.
which means that in practice it is a little less Controlled trials in patients with major
sedating. Placebo-controlled trials have shown depression have shown that in doses of 400 mg
an efficacy in the treatment of major depression, and greater, nefazodone is more effective than
although the relative efficacy of mirtazapine placebo and generally equal in therapeutic
against other antidepressants is not fully clear activity to comparator drugs (Rickels, Schwei-
(Bruijn et al., 1996; Davies & Wilde, 1996). zer, Clary, Fox, & Weise, 1994). As with
Mirtazepine is generally well tolerated, with trazodone, these studies have focused on out-
the most common side effects being drowsiness, patients with moderate depressive disorders.
dizziness, and weight gain. Nefazodone is usually given in two divided doses
starting at 200 mg daily with titration to 400 mg
6.06.7.5.3 Trazodone daily after about a week. The maximum dose is
600 mg.
Trazodone is a triazolopyridine derivative
Nefazodone is generally well tolerated with
with complex actions on serotonin pathways.
the most common side effects being headache,
Studies in vitro suggest that trazodone has some
loss of energy, dizziness, dry mouth, nausea,
weak serotonin reuptake inhibiting properties
and somnolence. It appears less cardiotoxic
but these are probably not manifest during
than tricyclic antidepressants and is less likely
clinical use. Trazodone is an antagonist at
than SSRIs to cause insomnia and sexual
serotonin2 receptors but its active metabolite,
dysfunction (Robinson et al., 1996).
m-chlorophenylpiperazine (mCPP), is a seroto-
nin receptor agonist. Trazodone also blocks
6.06.7.5.5 Venlafaxine
postsynaptic a1-adrenoceptors, which gives it a
distinct sedating profile. Venlafaxine is a phenylethylamine derivative
Several placebo-controlled studies have which produces a potent blockade of both
shown that trazodone in doses of 150±600 mg serotonin and noradrenaline reuptake. In this
is superior to placebo in the treatment of respect the pharmacological properties of
depressed patients. Trazodone also appears to venlafaxine resemble those of clomipramine.
have equivalent antidepressant activity to com- However, unlike clomipramine and other
pounds such as imipramine. Many of these tricyclic antidepressants, venlafaxine has a
studies were carried out in moderately depressed negligible affinity for other neurotransmitter
outpatients, and the efficacy of trazodone in receptor sites and so lacks sedative and
anticholinergic effects. Venlafaxine is classified of tryptophan is consumed daily in the typical

as a selective serotonin and noradrenaline Western diet. Most ingested tryptophan is used
reuptake inhibitor (SNRI). Venlafaxine has for protein synthesis and the formation of
been studied in both inpatients and outpatients nicotinamide nucleotides; only a small propor-
with major depression and compared with tion (about 1%) is synthesized to serotonin via
placebo and active comparators. Current 5-hydroxytryptophan. There is only weak
studies suggest that it is more effective than evidence that L-tryptophan has antidepressant
placebo and at least of equal efficacy to other activity, although it may be superior to placebo
available antidepressant drugs. Venlafaxine in moderately depressed outpatients. There is
also appears to be effective in depressed rather better evidence that L-tryptophan com-
inpatients, perhaps more so than fluoxetine bined with MAOI treatment can enhance the
(Clerc, Ruimy, & Verdeau-Pailles, 1994; Feigh- antidepressant effects of MAOIs. Similar sy-
ner, 1994). nergistic effects have been reported in some
Venlafaxine has a wider dosage range than studies of L-tryptophan combined with tricyc-
SSRIs, from 75 mg to 375 mg daily, in two lics, although overall the therapeutic effect of
divided doses. Higher doses are associated with this combination seems inconsistent (Chalmers
a greater incidence of adverse effects. The usual & Cowen, 1990).
starting dose of venlafaxine is 75 mg daily which L-Tryptophan is generally well tolerated,
may be sufficient for many patients. Upward although nausea and drowsiness soon after
titration can be considered where there is dosing are not unusual. In the early 1990s,
insufficient response, or if a faster onset of the prescription of L-tryptophan began to be
therapeutic activity is needed. associated with the development of a severe
The adverse effect profile of venlafaxine scleroderma-like illness, the eosinophilia-
resembles that of SSRIs, with the most common myalgic syndrome, in which there is a very
adverse effects being nausea, headache, insom- high circulating eosinophil count (about 20%
nia, and sexual dysfunction. Venlafaxine occa- of peripheral leucocytes). Associated symp-
sionally causes postural hypotension but, in toms were severe muscle pain, edema, skin
addition, dose-related increases in blood pres- sclerosis and peripheral neuropathy. Some
sure can occur. Blood pressure monitoring may fatalities occurred. It is now reasonably well
be advisable in patients receiving more than established that EMS is not caused by L-
200 mg of venlafaxine daily. Sudden disconti- tryptophan itself but rather by a contaminant
nuation of venlafaxine has been associated with formed in the manufacturing process used by
symptoms of fatigue, nausea, and dizziness. It is a particular manufacturer (Kilbourne, Philen,
recommended that the dose should be reduced Kamb, & Falk, 1996). L-Tryptophan remains
gradually over at least a one week period. available for the treatment of severe refrac-
Preliminary evidence suggests that venlafaxine tory depression when it is used as an adjunct
is less toxic in overdose than tricyclic anti- to other antidepressant medication. Patients
depressants (Feighner, 1994). receiving L-tryptophan require close super-
vision, including monitoring for possible
symptoms of EMS and regular blood eosi-
6.06.7.5.6 Bupropion nophil counts. L-Tryptophan should be with-
drawn if there is any evidence that EMS may
Bupropion is marketed for the treatment of be developing.
depression in the USA but not in Europe. It is a
unicyclic compound whose pharmacological
properties are not well characterized. It may,
however, have some activity as a dopamine and
noradrenaline reuptake inhibitor (Ascher et al., 6.06.8 MOOD-STABILIZING DRUGS
1995). Bupropion has activating properties, and Under this heading are grouped three agents,
early in treatment can cause restlessness and lithium, carbamazepine, and sodium valproate.
insomnia. However, it does not cause significant These three drugs have efficacy in the preven-
sexual dysfunction. Bupropion is associated tion of recurrent mood disorders and also in the
with an increased risk of seizures, particularly acute treatment of mania. Lithium also has
where the dose exceeds 450 mg daily (Rudorfer useful antidepressant effects in some circum-
& Potter, 1989). stances (Price, 1989), but the antidepressant
activity of carbamazepine and sodium valproate
is less well established. Lithium has also been
6.06.7.5.7 L-Tryptophan
shown to lower the frequency of aggressive
L-Tryptophan is a naturally occurring amino behavior in patients with learning difficulties
acid, present in the normal diet. About 500 mg (Nilsson, 1993).
Mood-stabilizing Drugs 153
6.06.8.1 Lithium to help detect these changes, but patients

should also be monitored clinically for signs of
6.06.8.1.1 Pharmacology
hypothyroidism, particularly lethargy and
The mode of action of lithium is uncertain. substantial weight gain. If hypothyroidism
Lithium does not affect neurotransmitters or develops and the reasons for lithium treatment
their receptors directly, but appears to have are still strong, thyroxine treatment should be
important effects on intracellular signaling added. Lithium has rarely been associated with
molecules, or second messengers, that are elevated serum calcium levels in the context of
activated when a neurotransmitter or agonist hyperparathyroidism.
binds to a specific receptor. Through these Lithium is also associated with reversible
actions lithium could exert profound effects on ECG changes that do not seem to be of
a wide range of neurotransmitter pathways. It particular consequence for cardiac conduction.
has been proposed that the effects of lithium Other changes include an elevated white count
may be particularly apparent when the turnover and occasional rashes.
and recycling of second messengers is increased, Most concern around the adverse effects of
and accordingly lithium may act preferentially lithium is centred on possible long-term renal
to inhibit overactive neurotransmitter systems damage. As mentioned above, most patients
(Lithium Mechanisms Study Group 1993). taking lithium have some mild impairment of
renal tubular concentrating ability. However,
this usually recovers when the drug is stopped,
6.06.8.1.2 Efficacy
although there are some reports of persisting
It is estimated that about 50% of patients cases. There have also been reports of tubular
with bipolar disorder will have a good prophy- damage in patients taking prolonged lithium
lactic response to lithium. Some patients who treatment.
respond well have a complete cessation of mood Several follow-up studies have examined the
swings, whereas others experience markedly effect of longer-term lithium maintenance
dimished symptomatology in which subclinical treatment on glomerular function. It has been
mood swings can still be discerned (Goodwin & concluded that long-term lithium treatment, in
Jamison, 1990). Lithium is also effective in the the absence of toxic blood levels, does not result
acute treatment of mania but may need to be in a lowering of renal filtering ability (glomer-
supplemented with antipsychotic drugs if psy- ular filtration rate) (Gelder et al., 1996).
chotic symptoms are present (Chou, 1991). However, although lithium may not signifi-
About 50% of patients with a depressive cantly lower the mean glomerular filtration rate
syndrome unresponsive to antidepressant drugs in groups of patients with bipolar illness, there
will show a clinical response if lithium is added are case reports of increases in plasma creatinine
to their drug treatment (Price, 1989). Lithium in lithium-treated subjects when other causes of
alone has some acute antidepressant activity, nephrotoxicity appear to be absent. Whether
most apparent in patients with an underlying lithium treatment, in the absence of toxic blood
bipolar disorder (Goodwin & Jamison, 1990). levels, can cause frank renal failure is unclear
(Gelder et al., 1996). With the current trends
towards long-term prophylaxis of mood dis-
6.06.8.1.3 Adverse effects
orders, it is clearly wise to monitor biochemical
Common side effects include tremor of the measures of renal function regularly. It seems
hands, dry mouth, a metallic taste, feelings of likely that the risk of nephrotoxicity will be
muscular weakness, and fatigue (Table 10). minimized by avoiding toxic blood levels and
Thirst and increased urine volume are also maintaining plasma lithium levels at the lower
common. Most patients taking lithium have end of the therapeutic range.
some minimal defect of renal tubular concen- Effects on memory are sometimes reported by
trating ability, but this rarely leads to clinical patients who complain of every-day lapses of
problems. A few patients, however, develop a memory, such as forgetting well-known names.
diabetes insipidus-like syndrome with frequent Although this impairment may be associated
passage of large volumes of water. with the mood disorder rather than lithium,
Weight gain during lithium treatment is there is evidence that lithium can impair certain
quite common, and partial hair loss has cognitive tasks in healthy volunteers (Glue,
sometimes been reported. Thyroid gland en- Nutt, Cowen, & Broadbent, 1987).
largement occurs in about 5% of patients Sudden discontinuation of lithium in patients
taking lithium. Lithium also interferes with with bipolar illness can result in the rapid
thyroid production, and hypothyroidism oc- development of mania in up to 50% of subjects.
curs in up to 20% of patients. Tests of thyroid This is thought to represent a rebound
function should be performed every six months phenomenon (Goodwin, 1994). Rates of relapse
Table 10 Some adverse effects of lithium and carbamazepine.
Effect Lithium Carbamazepine
Neurological Tremor, weakness, dysarthria, Dizziness, weakness, drowsiness, ataxia,

ataxia, impaired memory, headache, visual disturbance
seizures (rare)
Renal/fluid balance Increased urine output with Low sodium states, edema
decreased urine-
concentrating ability; thirst,
diabetes insipidus (rare),
edema
Gastrointestinal/hepatic Altered taste, anorexia, nausea, Anorexia, nausea, constipation,
vomiting, diarrhea, weight hepatocellular damage
gain
Endocrine Decreased thyroxine with Decreased thyroxine with normal TSHa
increase TSH,a goitre,
hyperparathyroidism (rare)
Hematological Leucocytosis Leucopenia, agranulocytosis (rare)
Dermatological Acne, exacerbation of psoriasis Rashes
Cardiovascular ECG changes (usually clinically Cardiac conduction disturbances
benign)
a
TSH = thyroid-stimulating hormone.
are significantly less when lithium is stopped abnormalities in the babies of mothers receiving
gradually over several weeks (Baldessarini, lithium in pregnancy. For example, a rate of 7%
Tondo, Floris, & Rudas, 1997). has been reported, with most abnormalities
affecting the baby's heart. However, a prospec-
tive study of 148 women found no increase in
6.06.8.1.4 Toxic effects congenital malformation in patients exposed to
lithium in the first trimester of pregnancy
Toxic effects of lithium are related to dose. compared with matched controls. These authors
Because therapeutic blood levels (0.5±1.0 mmol/ concluded that lithium did not appear to be an
1) are close to levels at which toxicity may be important human teratogen (Jacobson et al.,
experienced (4 1.5 mmol/l) it is important for 1992). However, this conclusion was based on
both patient and clinician to be aware of relatively few patients.
symptoms of toxicity. They include ataxia, poor Clearly, it is desirable for patients to be
coordination of limb movements, muscle medication-free during the first trimester of
twitching, slurred speech, and confusion. Such pregnancy, and the decision whether or not to
symptoms constitute a serious medical emer- continue with lithium treatment must be care-
gency for they can progress through coma and fully weighed. Important factors include the
fits to death. If these symptoms appear, lithium likelihood of affective relapse if lithium is
must be stopped at once and a high intake of withheld. If pregnant patients continue with
fluid provided. In severe cases renal dialysis may lithium, plasma levels should be monitored
be needed. There have been reports of perma- closely. Ultrasound examination and fetal
nent neurological damage in patients who have echocardiography are valuable screening tests
suffered from lithium toxicity. It is important to as the pregnancy progresses.
note that certain commonly used medical drugs, Patients with a history of bipolar disorder
such as thiazide diuretics and nonsteroidal have a substantially increased risk of psychotic
antiinflammatory drugs, can elevate lithium relapse in the postpartum period. In such
levels and cause toxic effects (Gelder et al., patients it may be worth considering the
1996). introduction of lithium shortly after delivery
to provide a prophylactic effect. However, it
should be noted that lithium is secreted into
6.06.8.1.5 Lithium and pregnancy
breast milk and that significant concentrations
Lithium crosses the placenta, and retro- of lithium can be measured in the plasma of
spective studies have found increased rates of breast-fed infants.
Mood-stabilizing Drugs 155
6.06.8.2 Carbamazepine Carbamazepine has also been associated with

low sodium states.
Carbamazepine was originally introduced as The use of carbamazepine in pregnancy has
an anticonvulsant and was found to have useful been associated with neural tube defects in the
effects on mood in certain patients. Subse- fetus. The risk is diminished by adequate folate
quently it was found to be beneficial in many intake.
bipolar patients, including those who had
proved refractory to lithium. The acute anti-
depressant effect of carbamazepine is not 6.06.8.3 Sodium Valproate
established (Post, 1991).
Like carbamazepine, sodium valproate was
first introduced as an anticonvulsant. In recent
6.06.8.2.1 Pharmacology years there has been increasing interest in using
the drug in the management of mood disorders,
Like certain other anticonvulsants, carbama- particularly acute mania and the prophylaxis of
zepine blocks neuronal sodium channels. It is bipolar disorder in patients unresponsive to
unclear whether this action plays a role in its lithium and carbamazepine. There is presently
mood-stabilizing effects. Like lithium, carba- little evidence that valproate has acute anti-
mazepine facilitates some aspects of brain depressant effects (McElroy, Kerk, & Pope,
serotonin function. 1987; Post, 1991).
6.06.8.2.2 Efficacy 6.06.8.3.1 Pharmacology

In the treatment of acute mania, carbamaze- Valproate is a simple branch-chain fatty acid
pine is of about equal efficay to lithium. In the with a mode of action that is unclear. However,
prophylaxis of bipolar illness, carbamazepine is there is some evidence that it can slow the
also about as effective as lithium, although the breakdown of the inhibitory neurotransmitter
quality of the trials has been criticized (Dar- GABA. This action could account for the
dennes, Even, Bange, & Heim, 1995). Based on a anticonvulsant properties of valproate, but
survey of controlled and uncontrolled trials whether it also underlies the psychotropic
(Post, Denicoff, Frye, & Leverich, 1997) it is effects is unclear.
estimated that about 65% of patients with
bipolar illness show a clinically significant
prophylactic response to carbamazepine either 6.06.8.3.2 Efficacy
given alone or added to lithium. However, there There have been several controlled studies
is some evidence that in some patients an initial suggesting that valproate is effective in the acute
response can diminish with time suggesting that management of mania, but there are no
tolerance to the mood-stabilizing effects of controlled investigations of its efficacy in the
lithium can occur (Post, Leverich, Rosoff, & prophylaxis of bipolar disorder (McElroy,
Altschuler, 1990). Kerk, Pope, & Hudson, 1992). There have,
however, been numerous case series and open
studies that have reported useful prophylactic
effects of valproate in patients unresponsive to
Adverse effects with carbamazepine are lithium and carbamazepine, including those
common at the beginning of treatment (Table with rapid cycling mood disorders (McElroy
10). They include drowsiness, dizziness, ataxia, et al., 1987, 1992; Post, 1991).
diplopia, and nausea. Tolerance to these effects
usually develops quickly. A potentially serious
side effect of carbamazepine is agranulocytosis,
although this complication is very rare (var- Common side effects of valproate include
iously estimated from 1 in 10 000 to 1 in 125 000 gastrointestinal disturbances, tremor, sedation,
patients). A relative leucopenia is more com- and tiredness. Other troublesome side effects
mon, with the white cell count falling in the first include weight gain and transient hair loss with
few weeks of treatment, though usually remain- changes in texture on regrowth. Patients taking
ing within normal levels. Rashes occur in about valproate may have some elevation in hepatic
5% of patients. Elevations in liver enzymes may transaminase enzymes; provided this increase is
occur and, rarely, hepatitis has been reported. not associated with hepatic dysfunction the
Carbamazepine can also cause significant drug can be continued while enzyme levels and
disturbances of cardiac conduction, and there- liver function are carefully monitored. How-
fore is contraindicated in patients with preex- ever, there have been several reports of fatal
isting abnormalities of cardiac rhythm. hepatic toxicity associated with valproate; thus
far these reports have been confined to children Where psychological treatments have not
taking multiple anticonvulsant drugs. Valproate helped or are not available, buspirone or
must be withdrawn immediately if vomiting, antidepressant drugs rather than benzodiaze-
anorexia, jaundice or sudden drowsiness occur. pines should now be used for longer-term
Valproate may also cause thrombocytopenia treatment of GAD. The choice will lie between
and may inhibit platelet aggregation. Acute a sedating compound, such as a tricyclic
pancreatitis is another rare but serious side antidepressant, or nonsedating treatments such
effect, and increases in plasma ammonia have as buspirone or an SSRI. Although, sedation
been reported. Other possible side effects include has some advantages for patients with sleep
edema, amenorrhoea and rashes. The use of disturbance and agitation, in the longer-term,
valproate in pregnancy has been associated with buspirone or SSRIs are likely to be as effective
neural tube defects and bleeding in the neonate. and have less risk of cognitive impairment.
There is little information about the combined
use of medication and psychological treatment
6.06.9 CLINICAL USE OF in GAD. There has been concern, however, that
PSYCHOTROPIC DRUGS the cognitive impairment produced by benzo-
6.06.9.1 Anxiety Disorders diazepines may decrease the ability of the
patient to carry out psychological treatments.
6.06.9.1.1 Generalized anxiety disorder
In generalized anxiety disorder (GAD) drugs
6.06.9.1.2 Panic disorder and agoraphobia
are generally used as an adjunct to psychological
methods of treatment (Table 11). Benzodiaze- A number of drug treatments are effective in
pines are now prescribed only for short-term use panic disorder. These include high potency
(2±4 weeks) in patients where anxiety is causing benzodiazepines such as alprazolam and clona-
severe distress and functional impairment. zepam, as well as tricyclic antidepressants such
Benzodiazepines have a number of advantages as imipramine and clomipramine (Lydiard &
as short-term treatment in that they are rapidly Ballenger, 1987; Modigh, Westberg, & Eriks-
effective and have a wide safety margin. It is son, 1992). SSRIs are also effective and
usually best to give benzodiazepine treatment paroxetine is licensed for the treatment of panic
on an as-required basis in doses of 2.5±5 mg. disorder in the UK (Oehrberg et al., 1995).
Intermittent use of this nature is less likely to MAOIs are good antipanic drugs but are little
result in tolerance (Tyrer, 1997). used because of their adverse food and drug
Tricyclic antidepressant drugs and trazodone interactions (Nutt & Bell, 1997; Nutt & Glue,
have also been shown to be effective in GAD in 1989).
the same doses that are effective in treating Overall, all these drugs have efficacy in both
major depression (Rickels et al., 1993). SSRIs preventing panic attacks and lessening phobic
have not been formally tested in this disorder avoidance. However, antidepressants are diffi-
but clinical impression suggests that they are cult to use in panic disorder because initial
likely to be useful. The azapirone buspirone is treatment often produces symptomatic worsen-
also effective in GAD, particularly in patients ing and jitteriness. For this reason a low starting
who have not received significant prior benzo- dose and careful titration are required. How-
diazepine treatment. All these treatments take ever, to obtain the best clinical response it is
longer to work than benzodiazepines. Their necessary eventually to build the doses up so
ultimate effect over 6±8 weeks, however, is at that they are similar to those required in major
least as great (Cowen, 1997). depression (Mavissakalian & Perel, 1995). The
Table 11 Spectrum of activity for anxiolytic drugs.
Generalized Obsessive-compulsive
Drug anxiety disordera Panic disorderb Social phobia disorder
Benzodiazepines + +c ?c 0
Buspirone + ± ? 0
TCAs + + ± 0d
SSRIs ? + + +
MAOIs ? + + 0
a b c
+ = effective; ± = not effective, ? = uncertain. With or without agoraphobia. High potency compound (alprazolam, clonaze-
pam). dClomipramine effective.
Clinical Use of Psychotropic Drugs 157
high potency benzodiazepines, alprazolam, and although there is evidence from controlled trials
clonazepam, have the advantage of not causing that treatment with SSRIs and MAOIs may
increased anxiety early in treatment and this confer benefit (van Vliet, den Boer, & Westen-
makes them easier to use (Schweizer, Rickels, berg, 1994; Versioni, Nardi, & Mundim, 1992).
Weiss, & Zavodnick, 1993). However, with- Interactions of drug treatment with psycholo-
drawal of these drugs in patients with panic gical treatment have not been systematically
disorder can be very difficult (Fyer et al., 1987). studied.
Cognitive behavior therapy is effective in
panic disorder and has the advantage that
relapse is less common after the end of 6.06.9.2 Insomnia
treatment than it is after drug treatment is Insomnia is a common health problem in
withdrawn (Clark et al., 1994). Antidepressant community samples (Lasagna, 1995). Although
treatment retains a useful place in patients who hypnotic drugs such as temazepam and zopi-
are not able to benefit from cognitive therapy. It clone are effective in the short term, continued
is posssible that the combination of behavior use may result in tolerance and rebound
therapy and antidepressant treatment might insomnia often occurs upon drug discontinua-
produce increased efficacy (de Beurs, Vanbalk- tion. It is recommended therefore that hypnotic
om, Lange, Koele, & Van Dyke, 1995). A small drugs be employed only for short-term treat-
potentiation of treatment efficacy was also ment. Many people with insomnia use other
apparent when alprazolam was added to pharmacological remedies such as sedating
exposure therapy for patients agarophobia antihistamines or alcohol (Lasagna, 1995).
and panic. However, alprazolam-treated pa- These measures are generally of limited utility.
tients showed less improvement after the end of The role of the pineal hormone melatonin is
the study (Marks et al., 1993). Alprazolam also arousing increasing interest but controlled
produced significant impairments on word longitudinal studies are rare (Gafinkel, Laudon,
recall tasks (Curran et al., 1994). Nof, & Zisapel, 1995).
There are a number of psychological
6.06.9.1.3 Obsessive-compulsive disorder methods of helping insomnia (Morin, Culbert,
& Schwartz, 1994). These should be preferred to
Drugs that produce marked potentiation of drug treatment in the first instance because they
brain serotonin function, such as SSRIs and have fewer adverse effects and their benefits, if
clomipramine, are effective in obsessive-com- obtained, are likely to persist for longer.
pulsive disorder (OCD). About 50% of patients
are much improved, although recovery is rarely
complete. Similar doses or somewhat higher are 6.06.9.3 Depression
used in the treatment of OCD as in major
depression. Both obsessional ruminations as Antidepressant drugs are used in the treat-
well as rituals respond to drug treatment. The ment of major depression and dysthymia
time course of response is rather longer than in (Depression Guideline Panel, 1993). Antide-
major depression with a linear rate of improve- pressant drugs appear to be of definite value in
ment beginning at about 4 weeks and continuing more clinically severe depressions, particularly
for 12 weeks and more (Jenike, 1992). those that meet criteria for melancholic features
There is little evidence that drug treatment (DSM-IV) or somatic symptoms (ICD-10)
increases the effect of behavior therapy in (Depression Guideline Panel, 1993). Although
patients able to comply with this treatment some improvement in depressive symptoms may
(Cobb, 1992). However, drug treatment has a be seen in the first week of treatment, generally
role in patients who cannot undertake behavior antidepressant drugs can take 4±6 weeks to
therapy or who are unresponsive to it. Relapse exert clinically important effects (Depression
rates are much less after successful behavior Guideline Panel, 1993; Quitkin et al., 1996).
therapy than after withdrawal of antidepressant
drug treatment. It has therefore been suggested
6.06.9.3.1 Choice of antidepressant
that, where patients have improved with drug
treatment, behavior therapy may be added with As noted above several kinds of antidepres-
the aim of facilitating drug discontinuation sant treatment are available which are of
(Cobb, 1992). generally equivalent efficacy in the broad range
of depressed patients. For the more severely
depressed subjects, however, treatment with a
6.06.9.1.4 Social phobia
tertiary tricyclic antidepressant, such as ami-
There is less evidence about the utility of drug triptyline or clomipramine or the SNRI venla-
treatment in the management of social phobia, faxine, should be considered (Anderson, 1997).
For other patients the choice can be made sant medication may be more efficacious than
according to the symptom profile of the either alone in patients whose depression is
antidepressant and the needs of the patient. complicated by interpersonal and social diffi-
For example, in subjects striving to carry on culties, but few controlled trials exist to sustain
with their usual work and social activities, this opinion (Depression Guideline Panel,
relatively nonsedating compounds such as 1993).
lofepramine, nefazodone, SSRIs or venlafaxine There have been studies of drug and
would be suitable. Tertiary tricyclics may be psychotherapy interactions in the longer-term
helpful when sleep disturbance is severe or when treatment of depression. For example, Frank
rapid sedation is needed. In some patients, et al. (1990) found that interpersonal therapy
however, tricyclic antidepressants will be con- given once monthly delayed, but did not
traindicated because of their anticholinergic and prevent, depressive recurrence compared to
cardiovascular side effects. Sedating com- placebo medication and clinical management.
pounds suitable in this situation include trazo- In the same study interpersonal therapy did not
done and mirtazepine. With the exception of augment the effect of impiramine to prevent
lofepramine, tricyclic antidepressants should depressive recurrence. There is some evidence
not be prescribed where there is a risk of that cognitive therapy can decrease the risk of
deliberate overdose. MAOIs will generally be subsequent relapse (Blackburn, Eunson, &
used as second- or third-line drugs because of Bishop, 1986). If this is the case it could be
their food and drug interactions. a very useful treatment for the many patients
who wish to discontinue medication but are
unable to do so because of symptomatic
6.06.9.3.2 Prophylaxis of recurrent major
recurrence.
depression
Once a patient has responded to antidepres-
sant drug therapy, drug treatment is usually 6.06.9.4 Mania
continued for at least 6 months to prevent
Mania is generally treated with mood-
relapse of syptoms; this is called continuation
stabilizing drugs and antipsychotic medication.
therapy (NIMH Consensus Development Con-
In the USA antipsychotic drugs are avoided as
ference Statement, 1985). In patients with
far as possible because of the risk of movement
recurrent major depression longer-term pro-
disorders and treatment with lithium or
phylactic drug therapy is often required to
valproate preferred (Chou, 1991). It is im-
prevent frequent disabling recurrences. Gener-
portant to note that the plasma level of lithium
ally, if an antidepressant is effective in acute
effective in mania (0.8±1.2 mmol/1) is some-
phase treatment, it will provide a useful
what higher than the range recommended for
prophylactic effect during long-term treatment
prophylaxis (0.5±0.8 mmol/1) (Prien, Caffey, &
(Quitkin et al., 1996). However, some patients
Glett, 1992).
respond better to lithium prophylaxis or to the
In the UK, because of the risk of lithium
combination of antidepressant and lithium.
rebound upon sudden disontinuation (Good-
win, 1994), antipsychotic medication tends to be
6.06.9.3.3 Psychological therapies and used more in the treatment of acute mania. In
antidepressant drug treatment general, conventional antipsychotic drugs such
as chlopromazine and haloperidol are em-
Specific psychotherapies such as interperso-
ployed; there is little information on the efficacy
nal therapy (IPT) and cognitive behavior
of newer antipsychotic drugs such as risperidone
therapy are effective in the treatment of major
and olanzepine. Benzodiazepines may be em-
depression. In general, patients with more
ployed for sedation (Chou, 1991). The treat-
severe depression appear to do less well with
ment of mania requires skilled nursing and
psychotherapy. For example, both IPT and
psychological management but specific inter-
cognitive behavior therapy appear less effective
personal or cognitive therapies are not generally
in patients with disturbances of sleep architec-
used.
ture (Thase et al., 1997; Thase, Simons, &
Reynolds, 1996), a common feature of depres-
sion with melancholic features. It has also been 6.06.9.5 Prophylaxis of Bipolar Illness
reported that patients who fail respond to
cognitive therapy can subsequently show benefit Bipolar illness is a recurrent disorder and
with antidepressant medication (Stewart, Mer- prophylaxis with mood-stabilizing drugs is a
cier, Agosti, Guardino, & Quitkin, 1993). mainstay of treatment. A major problem in the
There is a strong clinical impression that management of bipolar disorder is lack of
combinations of psychotherapy and antidepres- compliance with treatment. This has a variety of
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6.07
Experiential Treatments:
Humanistic, Client-centered, and
Gestalt Approaches
LARRY E. BEUTLER, KEVIN BOOKER, and STACEY PEERSON
University of California, Santa Barbara, CA, USA

6.07.1.1 The Diversity of Experiential Therapies 165
6.07.1.1.1 Experiential theory as a method of study 165
6.07.1.1.2 Experiential theory as a set of assumptions 165
6.07.1.1.3 Experiential theories view the source of behavior 167
6.07.1.2 Chapter Overview 167
6.07.2 HISTORICAL DEVELOPMENT 167
6.07.2.1 Existential Models: The Rise of Logotherapy 167
6.07.2.2 Phenomenological Approaches: The Rise of Client-centered Therapy 169
6.07.2.3 Humanistic Approaches: The Rise of Gestalt Therapy 172
6.07.3 CONTEMPORARY DEVELOPMENTS 173
6.07.3.1 Theoretical Developments and Applications 174
6.07.3.1.1 Existential theories 174
6.07.3.1.2 Phenomenological theories 175
6.07.3.2 Humanistic Theories 176
6.07.3.3 Research and the Status of Experiential Therapies 178
6.07.1 INTRODUCTION even minor disagreements with former disciples

resulted frequently in the development of
The theoretical development of psychother- different ªschoolsº; old allegiances and friend-
apy has not been smooth; theories have evolved ships were lost, and theoretical constructs
largely through conflict and revolution rather became rigidly reified by the vigorous defenses
than through an orderly progression of evidence erected against annihilation by their propo-
and discovery. From the beginning, Freud nents. This history of dispute and division left a
demanded unswerving loyalty to his viewpoints, legacy of fragmentation in psychotherapy
an unrealistic expectation given that the topic of theory; hundreds of schools of thought have
discourse was, at that time, so poorly under- evolved with the very nature of evidence being in
stood, and that the concepts were so complex hot dispute. As clients and prospective clients,
and subjective. Freud's lack of sympathy as well as practitioners and scientists, this is the
toward those whose perspectives came to legacy that remains (Bergin & Garfield, 1994;
diverge from his own extended to a point that Freedheim, 1992).
163
164 Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches
In order to both capture the breadth of the are models based on ego-psychology, self-
field and to bring some order to it, it is useful to psychology, and objects-relations theory. ªEx-
conceptualize the field as being composed of periential Theory,º likewise, is comprised of
various overlapping levels of specificity. At least existential, humanistic, and person-centered
three such levels, systems, models, and theories, models of psychotherapy; within the behavioral
are necessary to capture the color and diversity school are radical behaviorism, social learning
of the field of psychotherapy. theory, and cognitive models. Each of these
Most theorists generally identify psychother- models poses a slightly different view of how
apy as evolving from three major systems or behavior is best changed and what aspects and
schools (Rice & Greenberg, 1992). Each of these patterns of motives are likely to be manifest in
intellectual systems continue in somewhat this process.
modified form from their initial beginnings A third and more specific ordering of theory
and in contemporary psychotherapy, are com- identifies specific theories of psychotherapy.
posed of models and theories, all of which share These theories typically are identified by certain
a common but distinctive view of what strategies and techniques that distinguish them
motivates behavior. The first system in this from others, even within the same model and
evolution is the collection of viewpoints that are system. Beck's theory of cognitive therapy is
often referred to as ªpsychoanalyticº or ªpsy- different from that of Ellis, for example, though
chodynamic.º This system is distinguished from they both are representative of a cognitive
the other two by its reliance on the concept of model of psychotherapy.
intrapsychic conflict as the basis of motivation Again, using the example of Experiential
and change. It arose with the ideas of Freud in Theory, within the model of existentialism,
the first two decades of the twentieth century, Daseinsanalysis and Logotherapy represent
and expanded through the contributions both of different, specific, theoretical contributions;
Freud's (former) disciples and from the applica- within the humanistic tradition, Gestalt
tion of his ideas to the theories that are known as Therapy and Redecision Therapy may be
ego-psychology, self-psychology, and object recognizable and distinct, and within a pheno-
relations. menological model, client-centered and person-
The second system in the evolution of centered therapies represent a line of evolution
psychotherapy came to prominence in the within a single theory.
1940s and 1950s. The behavioral school re- It bears mentioning that some believe that
placed the concept of intrapsychic conflict with two other systems or schools are sufficiently
ªReinforcementº as the basic motivating force distinct from their roots and are vying for status
of behavior. Conditioning, along with its as major, independent ªforcesº in psychother-
variants of learning by association and con- apy. Cognitive models of behavior are certainly
sequences, became the primary explanatory strong contenders for this status. Given that
construct. they pose the same motivational system that
Experiential schools, the ªthird forceº in characterizes behavioral theories, however, it is
psychotherapy (Rice & Greenberg, 1992), in unlikely that they qualify as a distinctive, major
contrast to the first two, view motivation as an system of the order of psychoanalytic, beha-
inherent struggle for integration and growth. vioral, and experiential theories. Similarly,
Thus, rather than being either driven by base while integrative models are widespread and
instincts, that were inherently destructive and influential, it is difficult to find a characteristic,
negative, or by external consequences, that were common, and distinguishing set of theoretical
inherently neutral in social value, self-actualiza- assumptions. These issues will likely prevent
tion assumed a decidedly positive valence, both cognitive and integrative models of
moving the individual toward increasingly intervention from being elevated to the level
social and enhancing ends. of a ªfourth forceº in psychotherapy.
Within each of these three systems there are a The very presence of these emerging and
variety of more specific models that describe competing systems, however, and the many
how the general system or movement is variations of theory that they represent, testify
translated to the specific example of psy- to the fragmentation of the field. Certainly, the
chotherapy. Each of these models share the diversity of psychotherapeutic approaches is
view of the larger group, the school, regarding substantially greater than might be judged if the
the basis of motivation, but differ in how they view were only at the level of the three broad
think these motives are manifest in psycho- systems to which theorists often refer. Though it
pathology and how they are addressed in seems that no one has taken the time to count
psychotherapy. Specifically, for example, with- them, there are clearly more than 400 specific
in the larger movement of ªPsychoanalytic theories and an indefinite number of intermedi-
Theory,º as has already been mentioned, there ate level models representing these.
Introduction 165
6.07.1.1 The Diversity of Experiential Therapies standing of each individual's unique personal
experience of the world in which they live. An
ªExperiential Therapyº is a broad designa- assessment of either the truth or value of this
tion within which there is a rich array of personal experience is not reliant on external
diversity. Humanistic, existential, and phenom- criteria, but on the person's own subjective
enological models are well accepted as being standard, their capacity to assess that standard
subdivisions of this general system. The identity through a process of reflective awareness, and
of the more specific theories that represent these the degree to which the resulting understanding
models, however, is less consistent. Some furthers the self-actualization of the individual.
theories are not easily classified within a single Knowledge, as defined through the conven-
model while others are blends of two or more. tional scientific standards of empirical observa-
Thus, some authors identify constructivist tion and externally measured but collective
approaches such as that of Kelly (1955) as an responses, is thought to be inadequate unless it
experiential theory (e.g., Bugental & McBeath, deepens an understanding of the unique
1995; Feshbach, Weiner, & Bohart, 1996), while phenomenology of the person.
others identify it as a variant of behavioral or The assumption that ªTruthº is in the
psychodynamic schools (e.g., Mahoney, 1993). patient's experience contrasts both with psycho-
The basis of this disparity is not obvious. While analytic and behavioral views. These latter
this variability suggests that there is a lack of views identify the therapist, rather than an
reliability in assigning at least some theories of external body, as the nucleus of knowledge. In
psychotherapy to general models or schools, it psychoanalysis, for example, insight and knowl-
also illustrates the cross-theory blending that is edge come from the therapist's or analyst's
a part of the experiential movement itself. interpretation, not from the patient, through the
Culturally, experiential philosophies are in- mechanism of interpretation. Thus, it is the
grained deeply in the values of hard work and analyst, not the analysand, who defines the
sacrifice, the values of the industrial and veracity and validity of experience. Likewise, in
Protestant revolutions. The evolution of these behavioral models, the therapist is considered to
theories was forever colored by the experiences be the expert or authority whose critical
of holocaust survivors and others who suffered understanding of behavior serves as the guide
the ravages of war and prolonged catastrophe for developing a technical correction. From the
(e.g., Frankl, 1961). While their theoretical therapist, not the patient, come the suggestions
roots date to the European philosophers of the and guidance that are then further supported by
eighteenth and nineteenth centuries, as a homework assignments from the therapist. In
domain of practice and service, experiential both of these views, the value of evidence is
therapies are largely a post-WWII development. proportional to the degree to which the
They represent the ªtransplanting of existential therapist-observer can remain objectively dis-
thinking from their chiefly European intellec- tant from the observed, the patient.
tual roots to a broader US audience of In contrast, in existential/humanistic analy-
nonmedical, unphilosophically sophisticated, sis, information flows from patient to therapist,
practicing counselors and therapistsº (Bugental rather than vice versa. The veracity of an
& McBeath, 1995, p. 112). experience is defined, for the experiential-
Rice and Greenberg (1992; modified from humanist, by self-reflection and personal
Tageson, 1982) point out that the various authenticity. The process of exploring and
theoretical variations within experiential theory identifying the nature and content of self-
share: (i) a reliance on phenomenology as a appraisal is not controlled by the therapist; it
method of study, (ii) an assumption that in-born is only facilitated and allowed to expand by a
actualizing tendencies motivate behavioral de- permissive clinician. It is this self-initiated
velopment and change, and (iii) a belief in growth that is the basis of healing.
individual choice as the causal locus of behavior.
6.07.1.1.2 Experiential theory as a set of

6.07.1.1.1 Experiential theory as a method of assumptions
study
Beutler, Bongar, and Shurkin (in press)
The methods that are used by experiential emphasize that three assumptions both distin-
psychotherapists are phenomenological and guish experiential therapy from psychoanalytic
individualistic, contrasting with the objective, and behavior therapy and represent the bases
external, and pluralistic methods of psycho- that bind the specific theories within the domain
analytic and behavioral models. It is assumed of experiential models together. These binding
that healing of the most complex problem will assumptions include the beliefs that: (i) there is
occur naturally by acquiring a deep under- an innate process that directs emotional growth;
(ii) constraining this inborn tendency from its considered by experiential theorists to be
normal process of unfolding produces distress fallacious and mistaken: (i) cognitive knowledge
and psychopathology; and (iii) removal of these can be separated from its emotional concomi-
constraints in a permissive environment releases tants, (ii) destructive acts are the products of
the healing process. Among the various models intense emotions, and (iii) constraint of emo-
and theories that constitute the experiential tions will protect the society from these
school, however, the priority and nature of these destructive acts.
beliefs change. Experiential theories assert that the very act
Within the mainstream of the tradition, self- of trying to protect a society by restricting the
actualization is the fundamental motivational emotional experiences of its citizens has the
force. It is an innate process that moves the paradoxical effect of increasing, rather than
organism to become increasingly complex, reducing, the likelihood of social discord and
balanced, and integrated. Thus, self-actualiza- violence. In this view, human problems are
tion requires emotional and sensory as well as caused, not by excessive expression, but by
cognitive input. Sensory and emotional experi- restraining and fragmenting the normal and
ences are thought to be necessary in order to necessary acts of thinking, feeling, sensing, and
insure the adaptive incorporation of new intuiting. Emotional constraint during the
cognitive information. As a person adapts, course of emotional development, in other
accommodates, and incorporates new informa- words, prevents incorporation of the very
tion, they naturally become more differentiated information that promotes integration and
and complex, both intellectually and interper- emotional growth.
sonally. Cognition becomes differentiated, Thus, rather than reducing the likelihood of
emotions become more varied, and behavior destructive acts, the efforts of society and
is increasingly discriminating. families to protect themselves from strong
Put in this way, self-actualization is not tied to emotions is thought to interrupt and fragment
a particular set of social values. However, some the experiences that allow people to develop
theories within the phenomenology and huma- social conscience and constraint. By becoming
nistic traditions extend the definition to include separated from their feelings, individuals may
the view that this growth process includes a then engage in destructive behavior without
movement toward greater productivity, self- feeling and sensing the consequences of these
sufficiency, creativity, and social adaptability. experiences. Both the benign failure to actualize
These definitions add a dimension of social and grow from new experience and the
ªgoodnessº and tie the theory more closely to malignant social destructiveness of impulsive
democratic social systems. behavior, therefore, are products of these
The assumption that self-actualization is an misdirected societal efforts.
inherent drive, drawing one toward growth and The third assumption that characterizes the
differentiation is probably less easily accepted experiential movement identifies the basis of
by existential theorists than it is by humanistic correcting the pathological effects of emotional
and phenomenological theorists (Rice & Green- constraint. This assumption defines the nature
berg, 1992). In existential models, self-actuali- and objectives of psychotherapy. It assumes
zation assumes a teleological definition in which that self-actualizing tendencies and powers that
growth derives from a pull from individualized have been aborted and fragmented can be
goals and aspirations rather than from a force reactivated in a therapeutic environment that is
that pushes one toward more abstract, societal characterized by unconventional acceptance of
goals. emotional experience. Such an environment is
The second assumption underlying experien- thought to unencumber, allow, and encourage
tial models identifies the basis for psychopathol- the reconnection of emotions and their expres-
ogy. This assumption points to social and sion. Behaviors become reattached to their
familial constraint and restriction of emotional emotional and sensory concomitants and con-
experience as a pathological force that consequences. By reconnecting these components
strains the natural process of growth and of experience, self-actualization motives are
differentiation. Beutler et al. (in press) observe reactivated, and the normal processes of
that most Western societies seek to restrain growing is allowed to continue.
intense emotions and discourage the develop- Experiential therapies provide an environ-
ment and expression of emotions. Experiential ment that is free from those arbitrary con-
theorists argue that this social constraint straints that are imposed against emotion and
separates an individual from some of the sensing by society and by families. The
experience that is necessary for effective in- psychotherapist endeavors to focus on, facil-
formation processing. This emotional con- itate, sometimes even to create experiences that
straint is based on three beliefs that are will magnify emotional and sensory reactions so
Historical Development 167
that it can penetrate defenses that have been the experiential school as examples, theories will
deadened by societal rules. The idea that human be traced from their post-WWII roots to their
emotional needs and drives are sources of status in the 1990s.
prosocial and proindividual behavior stands in The theoretical approaches that have been
contrast both with the negative nature of chosen to be representative of the development
humankind espoused by the id psychology of of the experiential system include the person-
psychoanalysis and with the tabula rasa view of centered (or ªclient-centeredº) therapy of Carl
personal development that characterizes most Rogers as an example of phenomenological
modern reinforcement psychologies. models; the Gestalt therapy of Fritz Perls as a
representative example of humanistic models;
and the Logotherapy of Victor Frankl as an
6.07.1.1.3 Experiential theories view the source example of existential models. These early
of behavior theories will be traced through an evolution
Experiential philosophies view individuals as that has produced a large array of contempor-
having ultimate control in their own lives. They ary modifications, variations, and approaches.
are thought to be active, not only in selecting An exhaustive description of the offspring and
their own behavior, but in constructing their research associated with the theories developed
own realities. It is out of this human capacity to by Rogers, Perls, and Frankl is not possible
make their own meanings of experience that within the framework of this chapter, but some
people construct goals and aspirations. It is also representative descriptions of the progeny of
on these meanings that people rely when faced each will be provided. The contemporary
with oppression, physical restriction, and Gestalt therapies of Greenberg and Daldrup
intellectual constraint in order to survive even and their colleagues will be described; the
the most atrocious of events. contemporary experiential therapies of Gendlin
The internal construction of meaning and and Mahrer and the contemporary existential
worth, in these eventualities, provides armor therapies of May, Maslow, and Bugental.
against external, destructive forces. Self-deter- Following a description of the historical roots
minism, in other words, is the prevailing of the three general theories, a more general
principle of the experiential movement, and perspective of the experiential system will
applies as much to thoughts and feelings as it describe developments in theory and practice,
does to behaviors. with a review of the research.
Experiential models attempt to counter the
victim-based mentality that characterizes both 6.07.2 HISTORICAL DEVELOPMENT
psychoanalytic and behavioral positions. These
latter systems assign people to a position of 6.07.2.1 Existential Models: The Rise of
being reactive either to instinctive urges, social Logotherapy
disruption, or reinforcements. Unlike these
alternative systems, experiential models assume Existential philosophy was transported to the
that people have a proactive posture. They field of psychotherapy from Europe via the
retain personal choice over their own percep- immigration of victims of the holocaust follow-
tions and meanings. This choice is optimized ing WWII. This philosophy found voice in the
when using and integrating information from US through Frankl's (1963) Man's search for
the full range of sensory, perceptual, and meaning, a treatise on survival in the concen-
cognitive experience. Both psychoanalytic and tration camps. Existential conceptualization of
behavioral models are viewed as excluding the individual sought to qualify and validate the
sensory and emotional experience and of experience of immediate existence, independent
exaggerating the significance of societal stan- of the theoretical projections about human
dards, insight, and behavior. psychological functioning that were implicated
historically by other theories of psychotherapy.
Frankl observed that interpersonal aliena-
6.07.1.2 Chapter Overview tion, related either to economic status or
political posturing, in conjunction with the
In the rest of this chapter, attention will turn precarious stability of social (family) structures,
to a variety of specific psychotherapy theories had the capacity to invoke debilitative anxiety.
that represent three models of behavior within Under a war-time period of constant life-threat,
the experiential tradition: existential, phenom- existentialism congealed as a response that
enological, and humanistic psychotherapies. restored the dignity of human life and resur-
The discussion will be restricted largely to rected the human spirit. Theories that explain
post-WWII developments. Using representative motivation by reference to homeostasis alone
approaches of each of the models that comprise were incapable of capturing the complexity of
the human struggle. To Frankl, therefore, it was prescribed by this meaning. Thus, Frankl
the act of striving for meaning that formed the believed, with Nietzsche, that he who has a
basis of motivation and the impetus for change. ªwhyº to live can bear with almost any ªhow.º
Frankl was born in 1905 in Vienna, the seat of ªBeingº to Frankl was trivariate, comprising
Freud's psychoanalysis. He founded the Youth spirituality, freedom, and responsibility. Spiri-
Advisement Centers in 1928, in response to a tual awareness was cardinal in the process of
long-standing interest in emotional well-being, being, taking precedence over freedom and
shortly before completing the work for his M.D. responsibility, what he called the ªpsychophy-
degree (1930). As a psychiatrist and neurologist, sicum.º To reflect on one's self, to project
he joined the faculty of the Department of meaning on experience, and to relate with forces
Neurology at the Rothschild Hospital in Vienna that were bigger than one's self were the
in 1936 and rose to Department Head by 1942. products of spiritual awareness. Freedom was
He published papers in prominent journals on second only to spirituality in the course of being.
the topic of psychiatric and neurological Freedom was defined as the capacity to rise
treatment of neurosis, beginning in 1939, and above instincts, to reject or accept experience,
became quite prominent in Vienna psychiatric and to do or not to do. Thus, a person had the
circles even before Hitler's 1939 invasion of freedom to pursue the objectives set by spiritual
Poland (Patterson & Watkins, 1996). awareness, and this freedom represented a
Frankl was interned both in Auschwitz and cardinal distinction between people and other
Dachau between the years of 1942 and 1945, animals. Yet the motivation to achieve meaning
where he lost virtually all of his family to the gas through spiritual consciousness and freedom
chambers. Man's search for meaning, which were not driving but pulling forces. That is, to
reported his experiences there, was published in Frankl, freedom and striving for meaning were
Vienna shortly after the end of the war. achieved because they drew people to action,
Subsequently he lectured widely in North not because it caused or compelled them to act.
America, capturing the imagination both of In his own struggle, Frankl was forced to deal
postwar Europe and of the American public. In with the conspiracy of the Nazis to force the
spite of his great influence on American oppressed to give up on life as they saw all of
psychotherapy, Frankl never immigrated to their familiar benchmarks, attachments, and
the United States. Following the war, he goals ripped away. He discovered that when life
assumed a full-time faculty position at the is thus controlled, and external objects and
University of Vienna where he rose to the rank relationships are lost, some basic ªhuman
of Professor in 1955. freedomsº remain; the God-given ability to
Frankl's experiences in Auschwitz and Da- choose the meanings that one assigns to
chau, and his intimate relationships with experience and to choose the attitude one holds
despair, hopelessness, depression, and imminent in and about the extant conditions and
death, qualify him as an effective authority on circumstances. It is this ultimate freedom to
suffrage and the human condition. Frankl choose attitudes that both informed Frankl's
found himself stripped to his naked existence experiences in the camps of Auschwitz and
by the atrocities of the Nazis; his father, mother, Dachau and that continue to have the capacity
brother, and even his wife had been sent to the to guide modern people's resolution of the
gas ovens. With the exception of his sister, existential dilemma.
Frankl lost his entire family to the Nazis. He The third factor in Frankl's conception of
faced the question of how a person who had lost being was responsibility. He came to believe that
virtually every possession, had every value spiritual awareness and choice were matters of
destroyed, who was hungry and suffering with responsibility. One is responsible both to find
the constant thought of imminent extermina- meaning in one's life and to act on that meaning.
tion, could find life worth preserving. Logotherapy (Frankl, 1961), therefore, placed
Responsibility and meaning are the hallmarks much emphasis on helping people assess the
of Frankl's theoretical construct of ªbeing.º implied responsibilities associated with the
These concepts speak directly to the condition of meanings they gave to their lives, and to act
the human sufferer who has made the concession on their own behalf. This process of developing
that they have nothing to lose except life, and meaning, claiming freedom, and taking on
that life itself is irrelevant without value and responsibility, however, was changing con-
choice. Reflecting on his own senseless suffering stantly with one's position and place in life.
and misery, Frankl concluded that to live is to The emphasis given by existential theory to the
suffer, and to survive is to find meaning in the ontological predisposition of the patient is the
suffering. Frankl believed that each individual most fundamental and salient marker for
was responsible for finding a purpose in life and human functioning, and is the lens through
that each must accept the responsibility that is which one is viewed.
In Logotherapy, human problems are seen as However, whereas existentialism arose from
arising in the form of neurotic anxiety that religious persecution and was supportive of
becomes attached either to the somatic, psy- contemporary religious views, the Client-cen-
chologic, or spiritual aspects of one's life. tered movement began as a reaction against the
Frankl gave special attention to the spiritual attitudes and philosophies that characterized
neuroses, those that arise from existential much of American Protestantism.
concerns as opposed to those arising from Carl R. Rogers (1902±1987) was raised in a
intrapsychic conflicts. Frankl had great faith in close-knit, Methodist family that was com-
and hope for the capacity of humans to rise mitted to the Protestant traditions of work and
above these anxieties. His accounts of life as a obedience. He struggled with the religious
prisoner resonate with examples of tremendous dogmas of his family, most of which seemed
human resilience and surprising capacity, of the arbitrarily to dictate how he should feel and
common man or woman, to transcend the what he should do. He viewed these dictates as
spiritual emaciation and weakness that so often constraining both of his intellectual growth and
is associated with human suffering. of his enjoyment, and found little comfort in the
Frankl bemoaned that spirituality, the ex- admonition that they should be accepted on
perience which is so central to human experi- faith alone. When, as an adolescent, his family
ence, was ignored by Freud and his followers. moved to a farm, Rogers became enthralled
He believed that it was from the spiritual sense with the science of agriculture. He devoured
of humankind that consciousness arose, and in a articles and books describing agricultural
corresponding fashion, Frankl identified not research and, deriving support from the dictums
only an instinctive unconscious, but a spiritual of science, he began to question his family's
one. By the process of uncovering the spiritual religious traditions. He found in science the
unconscious, esthetic awareness, love, and life hope that abstract principles and assumptions
values arose. could be put to a test. He also found hope for an
The will to live in the face of death, the will to escape from unbending religious doctrines.
hope in the presence of hopelessness, and Eventually, the development of a nondirective,
ultimately the ªwill-to-meaningº in the presence nondoctrinaire approach to helping people was
of meaninglessness were the basis for psy- his escape from the rigid views of a conservative
chotherapeutic applications of existentialism. ª(almost fundamentalist) Protestant Christian-
Thus, Frankl's goal in psychotherapy was to ityº (Rogers, 1959, p. 184).
help patients find meaning and responsibility in The route to the development of client-
life independent of their life's circumstance. In centered therapy passed through a number of
an attempt to help ªgroundº his patients, he stages as Rogers grappled with how to reconcile
would often ask, ªWhy do you not commit his scientific need for structure, his personal
suicide?º (Frankl, 1963). From their responses, needs for freedom, and the dogmatic and
he would seek the emotional basis for their controlling religion of his youth. Rogers
existence. originally called his approach to psychotherapy
True to the phenomenological assumption ªNon-directive,º a reflection of his de-emphasis
that characterized all of the experiential system, on therapist authority. Later, he adopted the
Frankl placed trust in the struggles of lost or term ªClient-centeredº (Rogers, 1951) to place
searching patients to find a meaning from which the focus on the process rather than the
to extract the basis for existential preservation; techniques. In later years, Rogers came to
personal elements and experiences with which prefer the term ªPerson-centeredº to reflect his
to illuminate the meaning in their lives. For evolving interest in the application of his ideas
some, meaning may be found in love for family; to environments beyond that of psychotherapy.
for others it may be in a relationship with a In adolescence, Rogers felt distant from the
church or organization. Whatever the scenario, family religion, a distance that was exacerbated
the intricate and delicate processes of a by the liberal views to which he was exposed at
therapeutic search for meaning involved in the University of Wisconsin, where he grad-
the integration or weaving together of these uated with a B.A. degree in 1924. Still trying to
threads of broken lives into a supportive maintain a foothold in religion, upon entering
pattern. young adulthood, he sought out a liberal
Christian denomination and undertook studies
as a minister in the Union Theological Semin-
6.07.2.2 Phenomenological Approaches: The ary. He found there a religious environment that
Rise of Client-centered Therapy gave him both the opportunity and the
encouragement to engage in free, philosophical
Like existentialism, client-centered therapy thought. This freedom of thought, however,
had its roots in religious tradition and practice. ultimately moved him even further from his
religious roots and he left the seminary after two On the one hand, he found these approaches to
years in order to enter the graduate program in be challenging because they forced him to search
clinical psychology at Columbia University's for and to find the order that he suspected to
Teacher's College. exist in clinical work. On the other hand, the
Rogers graduated with an M.A. (in 1928) and stranglehold that psychoanalytic views held on
a Ph.D. (in 1931), but during these years his clinical practice prevented his receiving the
break with formal religion became complete and encouragement and assistance he needed to
he began to seek other avenues for expressing his conduct research on his evolving theories. This
humanistic values. Client-centered Therapy led him to seek an academic environment in
may well have been his long-sought alternative which he hoped to find more support for his
to religion in providing meaning and structure research interests.
in his life. Rogers took a position in the Department of
Rogers initially was encouraged to work with Psychology and at the University Counseling
children and families, probably because in these Services at Ohio State University in 1940. His
prewar years this domain still offered the only hopes that his evolving theory and research
significant opportunity for a nonphysician to program were allied closely enough with
offer treatment. In 1928, when he was nearing experimentally based views of behavior to earn
the completion of his Ph.D. work, Rogers was him support from colleagues in this environ-
accepted as a Fellow at the Child Guidance ment proved to be frustrated. These were the
Center in Rochester, New York. Here, he was war years, a time when the concepts of personal
exposed to a deeply ingrained Freudian view- freedom were highly valued, but the encourage-
point. He found the rigidity of this viewpoint at ment of constraint, control, and obedience were
contrast to the free-thinking environment that also of signal concern. Devotion to personal
had first attracted him to Union Theological freedom, a concept that represented a national
Seminary, and reminiscent of the religion of his mantra during that time, synergistically at-
youth. Like religion, he found the speculative tached itself to Rogers' own history of con-
and nonempirical nature of Freudian methods straint and structure. The product was a unique
to be remarkably at odds with the statistical and form of psychotherapy that valued freedom,
methodological rigor that characterized both that saw an environment (including a therapy
the agricultural science of his youth and the environment) that reduced structure and
curriculum at Teacher's College. Ultimately, he authoritative demands as the avenue for its
rejected the rigidity of Freudian dogma as he realization, and that, paradoxically, sought
had rejected fundamental Methodism. In what evidence of its value through the structure
was a compromise between the contrasting and rigor of the scientific method.
values that he held, at once favoring structure At Ohio State University, Rogers discovered
and needing freedom, he adopted the structure that his notions of the subjective were at odds
of the scientific method as a means of with the rigid laboratory science of psychology
demonstrating the value of his freedom-giving that held sway in academia, however. It was
psychotherapy procedures. through this experience that Rogers became
After completing a Ph.D. degree from convinced that his theoretical perspectives,
Columbia Teachers College, Rogers continued indeed, represented a new direction in psychol-
as a staff member and Director of the Child ogy. His ideas flowered while he was in Ohio,
Study Center as it merged with the University of but the fruit emerged later, while he was at the
Rochester. He spent nine years in this position, University of Chicago (1945±1957).
ending his tenure there in 1940. During these WWII opened the door for psychologists to
years, America was in heated debate about provide services to adults. The needs, both for
entering the European war. Scant attention was mental health treatment and for vocational
given to other social ills. Rogers found that his guidance, that were exacerbated as veterans re-
interest in and work as a psychotherapist were entered society at the end of the war, became the
not given great value either by his academic means for counseling and clinical psychology to
colleagues or by the courts and schools that separate from school and child psychology, and
purported to rely on psychological services. Yet, to enter the world of adult mental health.
in the midst of an eclectic and supportive group Correspondingly, Rogers found his niche at the
of colleagues in Rochester, he began to University of Chicago Counseling Center,
formulate his ideas and to conduct experiments where he served as the Executive Secretary
on the effectiveness of his nondirective methods. and Director and enjoyed the richness of
Rogers became familiar with the controver- working with individuals of varied back-
sial works of Otto Rank, and with that of grounds. He taught students of psychology,
Rank's devotees at the Philadelphia Child Study theology, education, human development, and
Center, and this work left its mark on Rogers. sociology, and carried on a practice that
included work with veterans, families, and theory is ever completely valid or invalid. The
young adults. His teaching was supplemented role of research is to see beyond the dogma of
by the responsibilities and excitement of a theory and search for the nuclear truths that
patient/client load that consumed 15±20 hours were germane to and common among all
per week. It was during these years that client- theories and that transcend the clinic, the
centered Therapy caught the imagination of the laboratory, and even the discipline of study.
field and became firmly established within While phenomenological understanding was
clinical and counseling psychology. necessary on the personal, therapeutic level,
In 1957 Rogers returned to his alma mater, understanding the nature of this phenomeno-
the University of Wisconsin, where he was to logical truth would require the objectivity of
serve on the faculties of both psychology and science. The structure of science provided the
psychiatry. His research continued to earn wide- best available protection against self-deception.
spread recognition there. His ideas caught on The structure of personality and the nature of
and widely dispersed research groups began adaptation outlined by client-centered therapy
developing and refining his ideas. Research on is found in the concept of the ªselfº (Rogers,
therapist-offered conditions promised both to 1951; 1961). The emergence of Self as a viable
establish psychotherapy's empirical base and explanatory concept provided a base from
provide a bridge across various theoretical which the therapist could justify a personal
points of view. identity in therapy and could directly encourage
In 1962, Rogers became a Fellow at the and foster personal choice on the part of
Center for Advanced Study in the Behavioral patients and clients.
Sciences at Stanford, California. By this time, In its focus on choice and freedom, client-
his interests in applying the client-centered centered therapy revealed its roots, not to be in
approach to group therapy were well en- existential crises, but in a reaction against
trenched and his ideas were expanding to controlling and oppressive religions that threa-
include community relations, education, and tened moral choice and self-governance. Unlike
other nontherapy environments. To foster these Frankl, to Rogers the threat was not to physical
ªperson-centeredº ideas, following his year at existence and humanness, but to mental and
Stanford, Rogers became a Resident Fellow at moral autonomy. The correction was not to
the Western Behavioral Sciences Institute in La move closer to the mysteries of spiritualism and
Jolla, California. He went on to found and subjectivity, but further away, clearly reflecting
direct the Center for the Studies of the Person the different religious experiences of the two
there, and remained in that position, as authors. While Frankl found solace in religious
Founding Fellow and Resident Fellow, until philosophy, Rogers found it constricting. But
his death in 1987 (Patterson & Watkins, 1996). client-centered therapy, no less than the whole
As might be guessed from his history, Rogers of existential approaches, offered both a
was preoccupied with establishing the science positive view of growth and hope for freedom
and the practice of psychology as an integrated from mental domination. Client-centered ther-
discipline. Writing in 1959, he summarized the apy added psychotherapy research methodolo-
relationship between science and practice in gies to the other important and respected
very contemporary terms. He asserted that methods used by other humanists to understand
while research and theory share the common the processes of change.
goal of bringing order to experience, their The essence of client-centered therapy was
methods frequently are incompatible. However, summarized in Rogers (1993/1997) classic
he maintained that scientific knowledge can paper, ªThe necessary and sufficient conditions
come from clinical observations as well as of therapeutic personality change.º Though
through controlled research; in fact, naturalistic subsequently criticized for assuming an all-
observation is frequently the first step in important position as both necessary and
empirical research. He considered traditional sufficient (Lambert, 1991), variations of these
controlled research paradigms as being too qualities have been adopted by most therapeutic
simplistic to understand the complex variables approaches as, at least, ªhighly desirable.º The
that affect human growth in psychotherapy. conditions emphasized the importance of an
Rogers observed that a progressive and helpful emotionally congruent therapist who is able to
science capitalizes on serendipity and chance; it convey empathic understanding and positive
captures in unexpected moments kernels of regard.
truth that cannot be preordered on demand While frequently interpreted as being a
within the laboratory. philosophy only about therapist qualities, in
Finally, he urged that the book should never truth, Rogers offered, in these principles, a view
be closed on any theory. Since every theory that included the patient variables and percep-
contains an unknown element of error, no tions in creating necessary conditions for
change. Specifically, he identified patient dis- direction of Professor Kurt Goldstein at the
tress or incongruence as a motivational con- Frankfurt Neurological Institute for Brain-
struct. This anxiety complemented the natural Damaged Soldiers. With the advent of WWII,
growth processes by providing the impetus to Perls took his family to South Africa and in
work and to engage the therapist. 1935, he established the South African Institute
There were other patient qualities hidden in for Psychoanalysis. In 1946, he emmigrated to
Rogers' treatise as well. For example, he the US having become disillusioned with the
asserted that the patient must perceive the arise of apartheid in South Africa.
therapist's empathic understanding and regard, By training, Perls was a psychoanalyst, but he
implying that a degree of interpersonal facility was heatedly dissatisfied with the dogma and
and competence, as well as a capacity for structure of psychoanalysis. He was also
realistic interpersonal appraisal, are necessary influenced by the experimental work of Kohler,
for effective work. In later explanations, it Wertheimer, and Lewin, with whose work he
became clear that Rogers was not suggesting gained familiarity during his early years in
that this therapy would be ineffective with those Germany. Other existential philosophers with
who lacked these skills, but that all individuals whose work he also became familiar also
had the capacity for the level and type of eventually affected his work, but initially he
sensitivity that would allow them to benefit was too preoccupied with orthodox psycho-
from a therapeutic environment. In his later analysis to assimilate their work (Perls, 1947).
book, On becoming a person, Rogers (1961) Perhaps this is why he came to identify more
revealed his ties to existentialism and humanism closely with psychology than with psychiatry.
as a method of understanding, as a set of Fritz Perls met Laura Posner in 1926 while she
assumptions about the nature of human was working on her Ph.D. in psychology. She
problems, and as a philosophy about the causal was to become his wife and cofounder of Gestalt
locus of change (Rice & Greenberg, 1992). therapy. Laura Posner Perls' family was very
The famous Rogers±Skinner debates (Kir- affluent and culturally enriched, while Fritz was
shenbaum & Henderson, 1989) highlighted from a lower middle-class Jewish family. These
Rogers' beliefs in personal choice and empha- class distinctions were to influence their rela-
sized the value he placed on the patient's tionship for many years.
responsibility for their own change experiences. Laura Posner Perls was heavily influenced by
While considering the locus of change to be Martin Buber and Paul Tillich who were
within the person, he asserted that free choice prominent contemporary existentialists. Laura
could only be expressed when certain environ- and Fritz Perls worked closely together for
mental events and conditions are present. The nearly 25 years until they separated in the 1950s.
therapeutic environment was designed to con- Fritz Perls wrote his first book Ego, hunger and
sist of those contextual conditions. The ther- aggression subtitled ªA Revision of Freud's
apist's sensitive support and the client's theory and Methodº in 1941 and 1942 while
willingness to explore work synergistically to serving as a captain in the South African
foster the conditions for growth. Medical Corps. Although it was not for many
years that the name and character of ªGestalt
therapyº was succinctly expressed, this first
6.07.2.3 Humanistic Approaches: The Rise of book introduced many of the Gestalt concepts
Gestalt Therapy which would later become central ideas in
Gestalt therapy.
Gestalt psychotherapy took root as a During the years that Fritz and Laura Posner
counter-response to the negativism of psycho- Perls were together, Gestalt therapy was
analysis. It was a logical extension of the developing and maturing, although the parti-
movement toward personal direction and free- cular contributions of Laura Perls often are
dom that characterized Logotherapy and client- obscured in the available writings. Although
centered therapy. It did so, however, without Gestalt therapy was first introduced in the US
relying on the abstract concepts of spirituality of by Fritz and Laura Perls, it was not until Fritz
these former approaches. Although the emer- found a home at Esalen Institute at Big Sur,
gence of Gestalt therapy is generally thought to California, in the 1970s that Gestalt therapy was
have been in the postwar years of the 1940s, its recognized nominally as an independent theory.
genesis actually was some 20 years earlier. It was Fritz, not Laura, who came to be
Friedrich (Fritz) Perls (1893±1970) was born recognized as the discoverer, the father, and
in Berlin (Patterson & Watkins, 1996). He developer of Gestalt therapy. His estranged
obtained an M.D. degree from the Frederich wife, Laura Perls, was residing in New York
Wilhelm University in 1920. Following his City, outside the mainstream of the human
medical training, Perls worked under the potential movement which was beginning in
Contemporary Developments 173
California. She published few papers, and her the nature of perception and information
contributions to the theory and methods of processing, as well as from literature on defense
Gestalt work were known only to a handful of and psychopathology. At the same time,
people (Corsini & Wedding, 1989). traditionally it has eschewed psychotherapy
Those familiar with the work of Laura, and outcome research. This priority of values
Fritz Perls note interesting differences in how contrasts with client-centered therapy, for
they implemented Gestalt therapy. One of the example, that has always valued outcome
most noted of these differences pertained to the research, but has given little acknowledgment
dimension of control and permissiveness that to research on psychopathology and personality
they applied in treatment. Laura employed development.
procedures that were characterized by apparent Still another distinguishing aspect of Gestalt
permissiveness, while Fritz's work emphasized therapy is its adoption of a holistic view of
therapist authority and control (Hatcher & behavior. It regards individuals as being
Himmelstein, 1976). inherently integrated; their behavior reflects
The 1930s and 1940s were a dynamic time for an integrated system whose collective activity
Fritz Perls. He was heavily influenced by a cannot be understood by simply viewing
number of prominent people including Wilheim isolated acts or structures. This humanistic
Reich, who was Perls' analyst in the 1930s, view is borrowed from Rank, whose concept of
Karen Horney, and Otto Rank. Horney was the ªtotal organismº contrasts with the psycho-
said to have directed the young and rebellious analytic view that separated mind and body and
Perls to a very eccentric and rebellious Reich. divided the psyche into discrete elements, for
Most notable in his influence was Reich, who example, id, ego, superego, that engaged in a
introduced Perls to a theory of psychosomatic struggle for power over one another. Instead,
medicine that considered physical movement Gestalt theory asserts that people struggle and
and symptoms as the body's armor against experience conflict because of the difficulty of
threat (Perls, 1947). The body work and incorporating new information into perceptions
physical techniques of Gestalt therapy was a based on old knowledge.
product of this earlier association. Finally, Gestalt therapy defined self-actuali-
However, it was Freud's theory of psycho- zation in a manner that contrasted with other
analysis that provided Perls with a theoretical experiential approaches. Self-actualization was
framework for all of his future thinking; despite reflected in balance, differentiation, and inte-
their differences, psychoanalytic theory was the gration of cognitive, sensory, and emotional
major foundation upon which Perls built his systems, rather than a motive toward social
understanding of human behavior, and it was goodness. The ability of conceptual systems to
psychoanalytic theory that he used as a communicate was manifest in the concept of
standard against which to evaluate his own self-response-ability, that is, the ability to
emerging theory. In Fritz Perls' autobiography, choose to be active and to overcome apathy.
In and out of the garbage pail (Perls, 1969), he Rather than encouraging social compliance, as
makes the following comment on Freud, ªRest might psychoanalytic therapy, Gestalt therapy
in peace, Freud, you stubborn saint-devil- encourages social rebellion and individualism.
genius,º reflecting his own ambivalent attitude
toward both Freud and psychoanalysis.
Gestalt therapy differs from other systems 6.07.3 CONTEMPORARY
and models in a number of important ways. For DEVELOPMENTS
example, Perls accepted psychoanalysis as a
general theory from which his own view derived. This section will summarize some of the most
However, he chose to omit certain aspects of significant developments and extensions of
Freud's theory from his own view, such as existential, humanistic, and phenomenological
psychosexuality, the tripartite anatomy of the traditions. Both in the interest of space and
personality (id, ego, and superego), and the because time has resulted in an inevitable
nature of the unconscious. As applied to blurring of theoretical boundaries, no attempt
technique, these omissions led Perls to empha- will be made to maintain clear distinctions
size how rather than why, and explored among these models. Existential theories have
experience within the ªhere and the nowº rather become more phenomenological and humanis-
than the ªthere and then.º tic ones have become more existential. While
Another difference is in the value assigned to some of the more visible theorists within these
various bodies of scientific research. Gestalt different systems will be mentioned no attempt
therapy draws from a broader scientific litera- will be made to be inclusive or exhaustive and
ture than most systems of psychotherapy. It detailed consideration to the fine distinctions
placed greatest value on research that describes among their points of view will not be given.
This will allow a summary of the more mechanisms of behavior, using language and
important findings from the research. concepts that are constructed by their theore-
tical orientation. He pointed out that both the
6.07.3.1 Theoretical Developments and experience of and resolution of anxiety was
Applications often aborted by therapists and other observers
when they construed the patient's experience in
6.07.3.1.1 Existential theories
ways that forced it into line with their own
Experiential theories have continued to conceptual frameworks.
expand, but probably at a lower rate than in The tendency of therapists to filter percep-
their heyday of the 1970s. Theories have become tions of the patient through a rigid lens of
more integrative of phenomonological, huma- theoretical views clouded their ability to
nistic, and existential perspectives, and have accurately perceive and relate to the patient.
been applied to an increasing array of problems, More importantly, it frustrated the objective of
formats, and environments. bringing the patient into contact with the
Because they did not arise from a single anxiety, preventing self-knowledge and resolu-
strand of philosophy, it is difficult to find a tion. He pointed out that a rigid or dogmatic
coherent direction of development that has theory prevented the therapist from adopting a
characterized the evolution of existential ther- phenomonological perspective. The therapists'
apy. Several major authors, both European and task is to separate themselves sufficiently from
American (e.g., Boss, Binswanger, Bugental, their own histories and dispositions to accu-
May, Maslow, Yalom), have offered contrast- rately perceive the meanings offered by a
ing directions. The works of May, Bugental, and patient's own developmental history.
Maslow have been particularly forward-looking Perhaps May's major contribution was his
and serve as a representative view of the field. piercing questions of fellow therapists. He
Rollo May, a psychoanalyst by training and provocatively asserted the possibility that what
practice, probably is most responsible for therapists view as an understanding of the
introducing existential therapy to the United patient is, in reality, a projection of their own
States (Rice & Greenberg, 1992). Along with self-reinforcing theory.
Irvin Yalom, one of his major contributions The foregoing is not to diminish May's
(May & Yalom, 1984) was the blending of contributions to experiential theory. May's
existential and phenomenological viewpoints. vision was to understand how people become
Adopting the phenomenological view, he be- aware of their own growth and potential, that is
lieved that the personal experience of an one's ªbeingnessº (May, Angel, & Ellenberger,
individual person was the most important 1958). It is this phenomenon of becoming aware
vehicle to knowledge and understanding, and of one's beingness that characterizes May's
emphasized that a person could be understood most frequently noted contribution to theory,
through their own experiences more adequately the ªI-Amº experience.
than through a therapist's theory about people The definition of the ªI-Amº includes the
(May, 1961; May & Yalom, 1984). Likewise, perception of what is real, but adds an
May thought that access to a patient's motiva- awareness of some emerging or existent poten-
tion for change was best obtained through an tial. Thus, a person exists in the present but with
exploration of the meanings, ideals, and goals the potential to become (May, 1961). This
that directed their life. dynamic aspect of self experience is central to
May's perspective began with a fascination the capacity to change; it is a precondition for
with anxiety and its meaning. This topic served their solution (May et al., 1958). The success of
as the basis for his doctoral dissertation in 1950 this solution, however, depends upon a therapist
as well as for a major book, The meaning of being able to help clients recognize and
anxiety (May, 1977) that was revised and experience their own existence.
reprinted several times. He saw anxiety, defense, May's ªI-Amº experience was so ontologi-
and abortion of developmental progress as the cally sound that it resonated through much of
inevitable products of conflict between goals the existential movement. The value of his
and aspirations and the demands and con- teachings seemed to help organize and guide the
straints of reality. However, in a viewpoint that search for what Bugental (1976) calls the ªlost
was reminiscent of Rogers and others, he sense of being.º May's ªI-Amº experience was
maintained that anxiety was growth enhancing. incorporated by Bugental into what he called
Pushing this point further, May launched an the ªexistential sense.º Like May, Bugental
insightful and provocative attack against psy- identified existing or being alive as the funda-
chotherapy theory. He noted that psychothera- mental concern of each human being.
pists, in the interest of effecting good therapy, Bugental, however, emphasizes that the
observe and attribute meanings to patterns or striving for existence supersedes the mere act
of being alive. It is a motivator that drives a 6.07.3.1.2 Phenomenological theories

person to become more vibrant and sensitive to
life. This quest for more life was inextricably The persuasive power of Rogers' ideas,
related to what he called the tragedy of the bolstered by ample research support (see
human condition, the inability both to recog- Beutler, Machado, & Neufeldt, 1994; Orlinsky,
nize and seize opportunities for fuller living. Grawe, & Parks, 1994), ensured that the
Bugental's concept of the ªlost beingº is a concepts of therapy process (therapist empathy,
person who was invisibly crippled, blind, and acceptance, regard, and congruence) have been
deaf to their own state of needing (Bugental, absorbed into the body of psychotherapy.
1976, 1987). This blindness to one's own state of Virtually all schools of psychotherapy find
emotional impairment represented a loss of the common ground in the views that a helpful
inward vision that made it possible to assess therapist is kind, respectful, caring, and under-
how well outer and inner experiences match. standing, the essence of the Rogerian ªneces-
Abraham Maslow was another major figure saryº conditions. The differences between the
in blending existential and humanistic theory. views of these therapist contributions and
His most noted contribution was his assertion of Rogers' earlier views are twofold: (i) these
a jurisdiction for psychology which dealt factors are considered to be minimal rather than
explicitly with issues of growth, motivation, optimal conditions for change, and (ii) none are
and creativeness (Maslow, 1968). His hierarchy considered to be necessary or sufficient of
of needs expressed his motivational theory and themselves. While there are a few ªpureº client-
replaced the unimotivational concept of self- centered theorists remaining, most within this
actualization, embodied in experiential theory, tradition have accepted these modifications to
with a conception that arranged this drive Rogers' original tenets.
within an array of more basic motives. The Out of this perspective, the translation of
ultimate questions of, ªWho am I?º and ªWhat Rogers' views over time are best embodied in
am I?º according to Maslow could only be extensions of his work to the broader domain of
answered by the individual asking the questions experiential therapy. The most prominent of
and proceeding through the hierarchically ar- these are represented by the writings of Laura
ranged answers. Rice, Eugene Gendlin, and Alvin Mahrer. These
Another contribution of Maslow's was his authors have added several specific procedures
conceptualization of inner awareness as a and philosophies to the general framework of
process of ªlistening to the impulse voicesº client-centered therapy. The major contribu-
(Maslow, 1971). He proposed that failures in tions of each of these writers, however, has been
personal growth, such as neuroses, were con- more often remembered for the technical
ditions in which these ªimpulse voicesº or procedures introduced than in the philosophical
ªinner signalº became weak or disappeared truths that they have added to understanding
altogether. With the inability to hear these (Hart & Tomlinson, 1970; Wexler & Rice,
signals, the person was incapacitated and 1974). Indeed, they all represent an emerging
became detached from their own essence. view that the therapist-offered conditions (em-
Maslow envisioned the result of detachment pathy, warmth, positive regard, and congru-
to resemble a zombie, the experientially empty ence) are insufficient to assure change. Thus,
person, rather than an anxious person as they offer the beginnings of a technology to
proposed by others. Anxiety represented a encourage and even to direct change (Rice &
level of being aware of disconnection, but Greenberg, 1992).
complete disconnection included a lack of By the mid-1970s, client-centered therapy
awareness of this disconnection. Maslow had become widely used as both a group and an
viewed the disconnected person as one who individual therapy. It was also becoming more
was empty, and believed that recovering the self cognitive. Information-processing theory was
must include the recovery of the ability to have popular and there was a concerted effort to
and recognize these inner signals (Bugental, integrate these views with the workings of
1987). client-centered therapy (Patterson & Watkins,
One major implication of this theory was in 1996). Laura Rice proved to be one of the
the nature of obsessive and compulsive beha- leaders in this movement. She formulated the
viors. The experientially empty person, lacking therapist's role as an assistant to the patient;
direction from within, turned to outer cues for together patient and therapist embarked on a
guidance and reassurance of existence. This process of learning to symbolize experience.
person relied on external cues, such as clocks, Rogers had discussed at length the idea that one
rules, calendars, schedules, agenda, and other of the goals of psychotherapy was for patients
people as a substitute for personal resources to begin to symbolize experience that was
(Maslow, 1971). outside of their awareness. Symbolization
represents the process of bringing information increasingly intense therapeutic experience

into focus and consciousness by giving it mental (Mahrer, 1983). In this process, cognition and
representation. This occurred largely, though emotions are salient to the extent that they occur
not exclusively, through words. within this genre of client experiencing.
Rice (1974) proposed that symbolization was Thoughts and feelings of the client are both
necessary in order to accurately process new accompanied and facilitated by focusing atten-
information and suggested that this process tion on bodily sensations. The key to unlocking
could be facilitated by ªEvocative Reflection.º the power of the therapy resides in the client's
This technique involved efforts to reactivate ability to allow these physical experiences to
emotional experiences by drawing the client's occur and to then give them meaning. In this
attention to key experiences. Then the client was process, feelings such as fear, anger, anxiety,
asked systematically to process or talk through excitement, gloom, as well as various cognitive
the experience in a heightened state of arousal. postures such as confusion are identified as
The emotional information was thought to be signals of the client's experience. Associations
more easily recoded and integrated by main- with these signals are then used to provide a
taining a heightened state of arousal and this landscape of meaning to the experiences.
was, in turn, enhanced by emotion-focused
reflections and focus.
Gendlin (1981) took the concept of focus a 6.07.3.2 Humanistic Theories
further step, increasing the attention given to
client-centered therapy's affect on sensory Integration has characterized the develop-
experiencing. Gendlin's method of focusing ment of humanistic models of psychotherapy. It
(Gendlin, 1981) included the use of nonverbal is no longer easy to identify a psychotherapy
exercises, such as directed imagery and magni- that is only humanistic. The infusion and cross-
fication of multisensory systems, designed to fertilization of cognitive therapy, experiential/
heighten awareness of sensory cues that signaled humanistic therapy, and client-centered ther-
the presence of emotional experience. apy, with traditional Gestalt therapy, for
Gendlin (1969) defined focusing as the example, have produced a rich array of
process in which people make contact with a interventions and novel directions to the
special kind of bodily awareness known as the conceptualization and application of psy-
ªfelt sense.º This felt sense was neither an chotherapy. When cross-bred with the active
emotion nor an intellectual emotional derivative orientation of Gestalt therapy, the experiential
(cognition). Rather, it was a bodily sense or approaches of Gendlin and Mahrer have
intelligence by which the body directs the person emphasized phenomenological interventions
to answers for personal problems. Moving within a provocative and therapist-guided
through the six stages of focusing, emotional medium. Some developments have highlighted
and cognitive awareness were thought to emerge the bridging of cognitive and experiential
as by-products (Gendlin, 1969). While Rice's theories while others have highlighted differ-
conceptualizations moved client-centered ther- ences between two somewhat different strands
apy ever closer to cognitive conceptualization, of experiential therapy, the nondirective,
Gendlin's moved it closer to existential and person-centered approach of Rogers and the
Gestalt perspectives. process-directive Gestalt approach (Greenberg,
Mahrer (1983, 1986, 1996) furthered this Elliott, & Lietaer, 1994).
movement of client-centered therapy toward Drawing on classical client-centered theory,
humanistic models, increasing its resemblence the person-centered approach regards the
to Gestalt therapy. In Mahrer's Experiential ªrelationshipº as necessary and sufficient for
therapy, the therapist and client both develop therapeutic change; humanistic experiential
images, the therapist's being an effort to approaches advocate the importance of an
replicate that of the patient. Laying side by active, process-directive intervention and cog-
side, the patient's experience is recreated in the nitive therapies focus on the role of conceptual
therapist's imagery and both attempt to focus structures in emotional dysfunction. The result
and move closer to the source of intense sensory is a number of approaches that stress active
and emotional experience. Mahrer (1989) has interventions that utilize emotional access to
attempted to manualize the key steps that a facilitate a change of perspective and the power
therapist and patient make in effecting his of which is deepened within the context of a
ªExperiential Therapy,º making this approach person-centered relationship.
both more researchable and more easily applied These evolving experiential/humanistic mod-
than conventional applications. els of therapy are applied in an increasing
The steps of Mahrer's Experiential/Huma- variety of formats. While most often used in an
nistic therapy are constructed to provide an individual format (Greenberg et al., 1994),
group therapy formats are practiced widely and who can identify past and present relation-
(Daldrup, Beutler, Greenberg, & Engle 1988), ships in which they are unable to express
and there are guidelines for their application to important desires are considered to be good
marital/couples therapy (Greenberg & Johnson, candidates for this type of therapy.
1988). Process-experiential therapy (Greenberg,
Focused Expressive Psychotherapy (FEP) is 1994) represents a similar model to FEP, but
an integrated experiential method for resolving places more emphasis on the integration of
blocked affect that is based on Gestalt therapy broadly-based nondirective (client-centered)
concepts. FEP works with a full range of relationship strategies with Gestalt therapy
inhibited emotions such as anger, fear, joy, and methods, and less emphasis on the role of
sadness with a particular emphasis on the range enduring patient traits. In this approach, there is
of emotions that surround the blocked expres- also an effort to integrate the interventions
sion of anger (Daldrup et al., 1988). FEP, first within a theory of cognitive±emotion relation-
attempts to access the client's schematic ships. This theory blends cognitive and experi-
memory by directing attention to potential ential theory (Greenberg & Safran, 1987). It
relationships in which these memories devel- assumes that the barriers to healthy functioning
oped. That is, the client is directed to painful result from (i) difficulties in finding words or
memories involving interactions with parents, images to symbolize experiences, and (ii)
spouses, children, and other significant mem- dysfunctional emotional schemes through
bers. Therapy is then designed to heighten the which to interpret experiences. Accordingly,
intensity and expression of emotion associated the goal of therapy is to enable client's to access
with the memories so that new schematic dysfunctional schemas within a therapeutic
structures can be realized (Engle, Beutler & environment in order to facilitate relevant
Daldrup, 1991). schematic change (Greenberg et al., 1993).
Although FEP attends to a full range of In process-experiential therapy, the client and
emotions which may be blocked or inhibited in therapist interact on two different levels. The
an individual, particular attention is given to the first level concerns the moment-by-moment
emotion of anger. FEP assumes a five-step effects that each of the therapist responses has
process that identifies emotions, specifies tar- following a client response. Accurate and
gets, determines markers of their presence, empathetic understanding of the client's words
implements experiments in change, and evalu- and messages provide the client with a feeling of
ates progress. The patient is actively engaged in being understood and received by the therapist.
all of these processes, but the therapist is It is anticipated that these therapeutic responses
responsible for leading them through the will allow the client to initiate work on
processes. The experiments are designed to increasingly more difficult and painful issues.
facilitate full awareness of the emotion itself as The second level on which the client and
well as its implications and genesis. therapist interact is viewed as more ªmolarº
FEP assumes that there are no ªgoodº or than the first. In this level, the therapist attempts
ªbadº emotions, per force, but rather that to enable the client to resolve the larger affective
emotions exist in all human beings. Why an problems that present themselves as in-session
individual chooses to react in a dysfunctional or therapeutic tasks. This requires emotional
enhancing way to a stressful event is reliant on experiencing, which is facilitated by attending
how accessible they are to emotional and to the emotions and senses in-the-moment,
sensory experience and the internalized rules under the assumption that so doing activates
that govern their behavior. The influence of emotional meanings that are then subject to
early experiences in childhood cannot be over- inspection and change.
looked in the formation of emotional develop- Process-experiential therapy is considered to
ment and the way in which an individual will be most appropriate for use among ambulatory
react in emotionally laden situations. If a child is outpatients who are experiencing moderate
unable to complete an emotional cycle, then the clinical distress and symptomatology. It is not
expression of this emotion (most notably, suited for clients with major thought disorder or
anger) will become frozen and part of the schizophrenia, impulse control or antisocial
individual's ªunfinished business.º personality patterns, or for those who may be in
In contrast to most forms of psychotherapy, need of immediate crisis intervention or case
FEP was designed to exert specific effects for management (e.g., acutely suicidal persons)
individuals who tend to constrain and inhibit (Elliott & Greenberg, 1995). It is not recom-
emotional expression, regardless of the specific mended for those who are unable to be self-
symptoms manifest. Individuals who can iden- reflective and those who find the therapist's
tify the hurtful relationships and experiences nondirective stance of not advising or inter-
that may have caused the inhibition of emotion preting to be unacceptable.
6.07.3.3 Research and the Status of Experiential the treatment of those with depression using
Therapies these controlled comparison procedures (e.g.,
Paivio & Greenberg, 1995). In a well-controlled
The suspicion with which experiential thera- investigation, Watson and Greenberg (1996)
pies have traditionally regarded both diagnosis compared a Gestalt-based experiential therapy
and empirical research has given way to produce with a client-centered intervention, observing
an emerging body of scientific evidence. Led by that while initial results were equivalent, long-
the efforts to blend Gestalt therapy with client- term effects favored the more active experiential
centered and cognitive therapy, research has approach.
included both naturalistic studies, randomized FEP (Beutler et al., 1987) has also been used
clinical trials of patients in clearly defined successfully in the treatment of individuals who
diagnostic groups, and meta-analyses of con- present with chronic organic pain. This domain
tributors to efficacy. Findings from all of these of study is based on the theoretical connection
research areas have generally supported the between chronic pain and depression. Beutler,
value of these approaches. et al. (1987) undertook the task of testing the
A prominent characteristic in the evolution of hypothesis that the intensity of pain correlates
this research is the increasing focus on differ- with the degree to which a person has persistent
entiating the client characteristics and problems difficulty expressing anger and controlling
for which experiential treatments are likely to be intense emotions (e.g., Beutler, Engle, Oro'-
effective. Specific focus has been on clinical Beutler, Daldrup, & Meredith, 1986). Using a
disorders such as anxiety disorders, major multiple baseline design with six patients who
depression, and personality disorders. Some had rheumatoid arthritis, Beutler et al. (1987)
research has looked at broader dimensions than found that FEP substantially activated beta-
those identified by diagnosis, particularly endorphin discharge and correspondingly re-
focusing on the differential response of patients duced depressive symptoms. This was particu-
with different coping styles (internalizing and larly true in the early and late phases of
externalizing), levels of resistance, and those treatment. However, the beta-endorphin re-
with physical symptoms. sponse was not correlated with alterations of
Greenberg et al. (1994) summarized the pain, suggesting that they functioned as stress
results of studies conducted since 1978, using markers more than as anesthetics of pain.
meta-analytic techniques. They compared pre- The evidence that certain ªtypesº of patients
to postchanges on symptom measures and, are particularly responsive to experiential
where possible, compared treatment effect sizes therapy has been the area in which the largest
to those observed among patients who were body of research has accumulated. Identifying
assigned to control or alternative treatments. clients by coping styles is another way of
They found moderate to strong effect sizes for identifying a ªtypeº of client who may benefit
experiential therapies, which compared favor- from experiential therapy. Whether a client is an
ably both with those observed among other externalizer vs. an internalizer may interact with
therapies and demonstrated that these treat- the type of treatment that the client will receive.
ments were more effective than no-treatment Beutler et al. (1991) found that those who coped
and placebo-treatment groups. with internalizing styles may profit more than
Naturalistic and quasi-experimental studies externally-oriented clients in client-centered or
have been used both to assess the relative nondirective therapies than from either cogni-
efficacy of experiential therapy relative to tive therapy or Gestalt-based therapy (FEP).
alternative treatments (e.g., Beutler & Mitchell, This has also been supported in several other
1981) and to assess the contributors to effective studies that have used different approaches to
outcome within different types of psychother- identify or measure internalization. For exam-
apy (e.g., Burgoon et al., 1993; Greenberg & ple, Tscheulin (1990) reported that self-oriented
Foerster, 1996; Hill, Beutler, & Daldrup, 1989; clients (internalizers) did better with a noncon-
Watson, 1996). Findings from these studies frontational therapist than with a confronta-
have suggested both that experiential therapies tional therapist.
may be at least as effective as alternative Several studies (see Greenberg et al., 1994)
treatments and that the level of arousal and have also concluded that high levels of client
experiencing induced by experiential methods resistance is a contraindicator to the direct-
facilitate the resolution of interpersonal conflict iveness that is inherent in many experiential
and reduce emotional distress. treatments, particularly those based on Gestalt/
Randomized clinical trial research designs humanistic (e.g., FEP, process-experiential
have also incorporated various experiential therapy) models. Specifically, highly resistant
therapies among the treatment comparisons. (high dominance, low submissiveness) patients
Especially promising results have been found in do better in client-centered or nondirective
Conclusions 179
therapies (Beutler et al., 1991, 1993) than in its presence makes one vulnerable to related
various directive, experiential therapies. In fears of being irrelevant, ignored, and non-
contrast, clients with low levels of resistance essential when these defining roles and posses-
do better in these directive alternatives than they sions are no longer present.
do in nondirective ones (Beutler et al., 1991). Experiential therapies concentrate on rede-
Although more research is needed on this fining self-views, a process that is generally
general theme, the findings suggest that clients thought to be natural and orderly when
with good interpersonal interests and skills may environments are conducive. Thus, the specific
be the ones who are most receptive to therapy models that constitute the experiential
experiential therapies. tradition all seek to remove obstructions to
these normal processes. By providing a permis-
sive atmosphere, they attempt to facilitate and
6.07.4 CONCLUSIONS enhance normal movement toward differentia-
tion of self, foster creativity, and stabilize
Experiential therapies comprise a heteroge- personal identity. Specific theories of psy-
neous collection of theoretically diverse inter- chotherapy vary in the degree of directiveness
ventions. They share certain assumptions about exercised by the therapist (Perls vs. Rogers), in
the nature of existence, the most reliable avenue the roles they assign to spiritual and teleological
to knowledge, and the mechanisms of symptom drives (e.g., Frankl vs. Rogers), and to the
development and change. Humanistic, existen- acknowledgment of other motives (e.g., Maslow
tial, and phenomenological traditions have had vs. Perls). However, they have in common
a long history within the fields of psychother- efforts to focus patient attention on the
apy. Existential views emphasize the impor- moment, to encourage attendance to present
tance of personal meaning and choice in sensory and perceptual impressions, and to
facilitating adaptation and survival in times expand therapist awareness of patient experi-
of crisis; phenomenological approaches have ence. While there is not now nor has there ever
emphasized the role of subjective experience, been absolute concordance among experiential
safety, and therapist-offered conditions as the models and therapists' theories, most have
avenues to understanding and change; and embraced this foundation principle.
humanistic models have emphasized the role of Modern developments of experiential thera-
active therapist interventions and the provision pies have blended theories, often including
of structure in facilitating change. principles and practices of cognitive and
Though deriving from different traditions, behavior therapies, as well as various compo-
these models of behavior have merged over nents from humanistic, existential, and phe-
time, both in their theoretical development and nomenological viewpoints. There has also been
in their methods of intervention. Central to a significant movement to reconceptualize
these emerging, amalgamated theories is a human experience within a developmental
common reliance on the concept of self as an perspective. In this conceptualization, emphasis
organizing principle of personality, and on self- is placed on growth as an immediately ontolo-
actualization as a foundation motivational gical experience, the person is a consciously and
principle. developing ªbeing.º These modern experiential
Experiential models of behavior have histori- therapies urge patients to focus both on
cally observed that the ªselfº has been defined in immediate experience and on the progressive
Western cultures indirectly. Thus, one identifies change and evolution of that experience as a
him or herself through either occupational role way of obtaining self-knowledge. This view
(e.g., ªI am a bus driverº) or through some other contrasts with both a static description of
external attribute or possession (e.g., ªI am personal meanings and with models of behavior
richº). Experiential therapies pose the thesis that emphasize either the effects of historical
that such definitions relegate self-definitions to experience in their own right, the roles of
the status of superficial attributes that can be unconscious drives, or the influence of biolo-
threatened or destroyed by external change. The gically determined behaviors.
result is an identity that lacks stability and that Traditionally, research has not been widely
is changeable and uncertain. The resulting accepted in the experiential traditions. This is
construct of ªselfº comes to serve only the with the exception of Carl Rogers, whose client-
most tenuous of functions, and in this process centered therapy introduced the scientific
projects a social image that is not authentic. method to the study of psychotherapy process
Such reliance on superficial structures provides and outcome. Led by active movements from
some limited protection from external threat client-centered and Gestalt traditions, however,
but does not provide protection from the most there has been a proliferation of research. This
basic of fears, the fear of nonexistence. Indeed, research has sought both to specify and
operationalize the application of experiential affect: A common link between depression and pain?
therapy so that they can studied objectively. The Journal of Counsulting and Clinical Psychology, 54(6),
752±759.
resulting manualized therapies have then ap- Beutler, L. E., Machado, P.P.P., & Neufeldt, S. A. (1994).
plied these methodologies to the study of Therapist variables. In A. E. Bergin & S. L. Garfield
various clinical conditions. The resulting studies (Eds.), Handbook of psychotherapy and behavior change
have found that experiential therapies produce (4th ed., pp. 229±269). New York: Wiley.
Beutler, L. E., & Mitchell, R. (1981). Psychotherapy
modest and reasonably strong effects when outcome in depressed and impulsive patients as a
compared either to patients' pretreatment function of analytic and experiential treatment proce-
status, control conditions, or comparison dures. Psychiatry, 44, 297±306.
treatments. Bugental, J. F. T. (1976). The search for existential identity.
Research also confirms that experiential San Francisco: Jossey-Bass.
Bugental, J. F. T. (1987). The art of the psychotherapist.
treatments can be adapted to treat specific New York: Norton.
client disorders (e.g., depression, chronic pain, Bugental, J. F. T., & McBeath, B. (1995). Depth existential
anxiety) as well as to a variety of client therapy: Evolution since World War II. In B. Bongar &
parameters. Research has been particularly L. E. Beutler (Eds.), Comprehensive textbook of psy-
chotherapy: Theory and practice (pp. 111±122). New
fruitful in applying different aspects or tasks York: Oxford University Press.
of treatments to different clients and situations. Burgoon, J. K., Beutler, L. E., LePoire, B. A., Engle, D.,
Therapists should be sensitive to the possibility Bergan, J., Salvio, M., & Mohr, D. (1993). Nonverbal
that clients who are high in autonomy or indicies of arousal in group psychotherapy. Psychother-
reactance may react negatively to the effects of apy, 30(4), 635±645.
Corsini, R. J., & Wedding. D. (Eds.) (1989). Current
the more process-directive experiential therapies psychotherapies (4th ed.). Itaska, IL: Peacock Publishers.
(e.g., Gestalt), whereas more dependent or Daldrup, R., Beutler L., Greenberg, L., & Engle, D. (1988).
externally oriented clients may react negatively Focused expressive therapy: A treatment for constricted
to nondirective therapies. Likewise, experiential affect. New York: Guildford Press.
and nonexperiential traditions may be differen- Elliott, R., & Greenberg, L. S. (1995). Experiential therapy
in practice: The process experiential approach. In B.
tially effective for patients who vary in coping Bongar & L. E. Beutler (Eds.), Comprehensive textbook
style. Experiential therapies may be most of psychotherapy (pp. 123±139). New York: Oxford
appropriate to those who are self-reflective, University Press.
have organized cognitive processes, and who are Engle, D., Beutler, L. E., & Daldrup, R. J. (1991). Focused
expressive psychotherapy: Treating blocked emotions. In
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relationships. psychotherapy & change. New York: Guilford Press.
Clearly more research is needed to study the Feshbach, S., Weiner, B., & Bohart, A. (1996). Personality
effectiveness of experiential treatments. Re- (4th ed.). Lexington, MS: D. C. Heath.
search is especially needed that assesses treat- Freedheim, D. K. (Ed.) (1992). History of psychotherapy: A
century of change. Washington, DC: American Psycho-
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disorders. However, it is also important to direct Frankl, V. E. (1961). Logotherapy and the challenge of
research attentions to studies of the transfer of suffering. Review of Existential Psychology and Psychia-
treatment to alternative settings, including try, 1, 3±7.
Frankl, V. E. (1963). Man's search for meaning (Rev. ed.).
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6.08
Social Skills Training and Problem
Solving
KIM T. MUESER
New Hampshire±Dartmouth Psychiatric Research Center, Concord,
NH, USA

6.08.2 THEORETICAL MODELS 184
6.08.2.1 The Stress±Vulnerability±Coping Skills Model 185
6.08.2.2 The Social Skills Model 185
6.08.3 ASSESSMENT 186
6.08.3.1 Components of Social and Problem Solving Skills 186
6.08.3.2 Assessment Strategies 187
6.08.3.3 Nonskill Factors which can Affect Social Competence 188
6.08.3.4 Integration of Assessment and Treatment 189
6.08.4 TRAINING TECHNIQUES 189
6.08.4.1 Motor Skills Model 189
6.08.4.2 The Problem Solving Model 189
6.08.4.3 Common Learning Principles 190
6.08.4.4 Basic Skills Training Techniques 190
6.08.4.5 Problem Solving Training 192
6.08.5 FORMAT OF SOCIAL SKILLS AND PROBLEM SOLVING TRAINING 194
6.08.5.1 Group Skills Training 194
6.08.5.2 Individual Format 195
6.08.5.3 Family Format 195
6.08.6 CLINICAL APPLICATIONS AND RESEARCH 195
6.08.6.1 Utility of Social and Problem Solving Skills Training 196
6.08.7 SUMMARY AND CONCLUSIONS 198
6.08.1 INTRODUCTION Hollin & Trower, 1986; Kleinmuntz, 1966;

L'Abate & Milan, 1985; Nezu & Nezu, 1989;
Over the past several decades, social skills O'Donohue & Krasner, 1995b). Although
training and problem solving training have various definitions of social skills have been
become some of the most widely practiced given by different clinical researchers, Bellack
techniques in clinical psychology, with applica- and Hersen offer one of the most comprehensive
tions spanning a broad range of adult disorders, descriptions of social skills as the:
and numerous books published on their
theoretical foundations, clinical applications, ability to express both positive and negative
and research (e.g., Bellack & Hersen, 1979; feelings in the interpersonal context without
183
184 Social Skills Training and Problem Solving
suffering consequent loss of reinforcement. Such tive behavior. By the 1970s, the critical
skill is demonstrated in a large variety of inter- ingredients of social skills and problem solving
personal contexts and involves the coordinated training had begun to be packaged, and research
delivery of appropriate verbal and nonverbal was underway evaluating the effects of skills
responses. In addition, the socially skilled indivi-
dual is attuned to the realities of the situation and
training on clinical populations.
is aware when he is likely to be reinforced for his Since the ªpackagingº of skills training
efforts. (1979, p. 512) procedures into standardized approaches, social
skills training and training in problem solving
have become some of the most widely practiced
Problem solving can be defined as the ability to clinical techniques in individual, group, and
recognize problems or formulate goals, and to family psychotherapy. Indeed, aside from clin-
develop strategies to successfully reduce or ical applications, the methods employed in skills
eliminate the problem or to make progress training are widely applied with nonclinical
towards achieving a goal. Training in social populations as well, such as in work with
skills and problem solving generally refers to the maritally distressed couples (Gottman & Rushe,
systematic application of principles of social 1995), training parenting skills (Forehand &
learning to the teaching of requisite skills McMahon, 1981), and teaching employment
hypothesized to underlie dysfunctions in inter- skills (Berg, Wacker, & Flynn, 1990). Thus,
personal relationships, mood, and functional although the focus of this chapter is on the
capacity (Davis & Butcher, 1985; Goldstein, application of skills training procedures with
1982; Larson, 1984). clinical populations, the principles of training
Skills training has a long history, and no single can be used to teach skills to any desired
individual can be given sole credit for developing audience.
the method. However, several contributors to This chapter begins with a review of theor-
the development of social skills training should etical models which serve as heuristics in
be noted. In the 1940s, Salter (1949) engaged understanding the impact of social and problem
individuals in role-plays in order to facilitate self- solving skills on interpersonal competence, and
expression and to help them overcome symp- the effect of skills on the course of psychiatric
toms such as depression and anxiety. In the disorders. Next, the fundamentals of assessing
1950s, Wolpe incorporated role-playing into his social and problem solving skills are described,
approach to psychotherapy based on reciprocal followed by a review of the basic procedures for
inhibition. Wolpe (1958) theorized that assertive training skills. Different formats for training
interpersonal behavior would be experienced as skills are then considered, including group,
incompatible with feelings of anxiety, leading to individual, and family-based approaches. Fol-
the extinction of anxiety in certain social lowing this, different clinical applications of
situations. Role-playing was used to help clients skills training are discussed, and research
develop more assertive interpersonal skills. In supporting the effects of training social and
the 1960s, Bandura's (1969) work on observa- problem solving skills is reviewed. The chapter
tional learning led to the formal inclusion of role concludes with a brief summary of social skills
modeling as a critical ingredient in social skills and problem solving training for clinical
training. Also around this time, Lazarus (1966) populations.
introduced the use of repeated role-plays paired
with instructions to facilitate the behavior-
shaping approach employed in social skills 6.08.2 THEORETICAL MODELS
training.
In their review of the history of psychological Two different models have been proposed for
skills training, O'Donohue and Krasner (1995a) understanding the impact of social and problem
note several other key influences on the solving skills on adaptive functioning and the
development of skills training which have course of psychiatric disorders: the stress±
played a prominent role in the emergence of vulnerability±coping skills model and the social
behavior therapy as a system of psychotherapy. skills model. These two models are compatible
These influences include the concepts of with one another, but each addresses a some-
behaviorism, instrumental and classical con- what different domain of functioning. The
ditioning, social role learning, and finally social stress±vulnerability±coping model addresses
learning theory, which posited that deviant or the relationship between social and problem
maladaptive behavior could be learned, rather solving skills, and the severity and the course of
than being the product of a disease, leading to severe psychiatric disorders such as schizophre-
interventions designed to unlearn such beha- nia and bipolar disorder. The social skills
viors or, as in the case of social skills and model, on the other hand, addresses the
problem solving training, to teach more adap- relationship between social and problem solving
Theoretical Models 185
skills, and functional capacity, including the ment skills; Meichenbaum, 1985). Third, clients
ability to achieve desired goals. Both of these can be taught social and problem solving skills
models are described below. to enable them to decrease stressors that
impinge upon them (Liberman, DeRisi, &
Mueser, 1989). Thus, social skills and problem
6.08.2.1 The Stress±Vulnerability±Coping solving training offer the promise of decreasing
Skills Model symptom severity and the course of psychiatric
illness by enhancing the ability of individuals to
This model provides a general framework for manage stress effectively.
understanding the interactions between psycho-
biological vulnerability, psychosocial stress, and
coping skills in determining the severity and 6.08.2.2 The Social Skills Model
course of psychiatric illnesses (Liberman et al.,
1986; Nuechterlein & Dawson, 1984; Zubin & This model addresses the relationship between
Spring, 1977). According to the model, psychosocial and problem solving skills on the one hand
biological vulnerability is necessary for the and social competence and social adjustment on
development of a psychiatric illness. It is the other (Bellack, Mueser, Gingerich, &
determined relatively early in life by factors such Agresta, 1997). Social competence is defined
as genetic loading and early environmental as the ability to achieve desired goals. Social
contributions (e.g., insults to the fetus such as adjustment refers to an individual's actual
in utero exposure to the influenza virus or attainment of those goals, including the ability
obstetric complications). Stress is defined as any to function in different social roles (e.g., worker,
environmental change or set of contingencies parent, spouse, student), to enjoy leisure and
that requires adaptation to minimize noxious recreational activities, and to care for oneself
effects (e.g., the loss of support from a significant (Mueser, Bellack, Morrison, & Wixted, 1990).
other, living in a stressful home environment, The social skills model postulates four assump-
stressful life events). Stress interacts with tions about the relationships between social
psychobiological vulnerability, increasing the skills and problem solving skills and social
chances of either developing a psychiatric functioning:
disorder, precipitating the occurrence of pre- (i) social competence requires the integration
viously dormant symptoms in an individual who of a set of component behaviors;
already has a psychiatric illness, or worsening (ii) impairments in component skills contri-
symptoms in a currently symptomatic indivi- bute to poor social competence;
dual. Coping skills are those abilities that enable (iii) social skills are learned or are learnable;
an individual to buffer the negative effects of (iv) deficits in social and problem solving
stress on psychobiological vulnerability. Coping skills can be rectified by skills training.
skills operate by either eliminating the source of As noted by Bellack et al. (1997) and
stress (e.g., solving a pressing problem) or by discussed further in Section 6.8.3, social skills
decreasing the unpleasant effects of stress (e.g., are not the only determinent of social function-
talking about feelings with friends after the ing; a wide range of other factors may also
death of a loved one) (Lazarus & Folkman, influence social adjustment, such as psychotic
1984). Social skills and problem solving skills symptoms, environmental conditions, and
are examples of coping skills. mood. However, skills are postulated to be
The stress±vulnerability model of psychiatric critical ingredients for interpersonal success,
disorders has important implications for treat- and deficits in these skills can be rectified
ment. Although psychobiological vulnerability through skills training techniques. While the
is assumed to be present at a relatively early age, stress±vulnerability model addresses the inter-
it can be decreased by encouraging adherence to face between skills and psychiatric illness, the
prescribed psychotropic medications and mini- social skills model is aimed at explaining the
mizing the abuse of substances which may relationships between skills, social functioning,
exacerbate psychiatric conditions (e.g., alcohol, and goal attainment.
cannabis, cocaine; Drake & Brunette, in press). It is beyond the scope of this chapter to review
The negative effects of stress on vulnerability the wealth of evidence supporting the stress±
can be minimized in three ways. First, clients' vulnerability±coping skills model and the social
exposure to stress can be reduced by modifying skills model (e.g., Trower, 1995; Yank, Bentley,
the environment in which they live (e.g., & Hargrove, 1993). The practical importance of
decreasing negative affect in the family envir- these models is that they have served as
onment; Dixon & Lehman, 1995). Second, heuristics for clinicians and researchers in
clients can be taught skills for minimizing the understanding the roles of social and problem
noxious effects of stress (e.g., stress manage- solving skills in social functioning, and the
interaction between these skills and the course and hence are of direct relevance to an
of psychiatric illnesses. Furthermore, these individual's social competence. In addition to
models have resulted in testable predictions the cognitive skills generally subsumed under
about the effects of social skills and problem the rubric of ªproblem solving skills,º other
solving training on social adjustment in psy- cognitive skills can also influence social compe-
chiatric disorders, predictions which have been tence. Abstract thinking can be crucial for an
empirically supported by research reviewed individual to grasp a concept related to solving a
later in this chapter. particular problem or achieving a desired goal.
Memory impairment may interfere with social
competence by rendering it more difficult for
6.08.3 ASSESSMENT individuals to learn from past mistakes or recall
This section discusses: (i) the components of critical features of situations. Cognitive func-
social and problem solving skills; (ii) the range tioning has been found to be a robust predictor
of strategies for assessing skills; (iii) nonskill of psychosocial adjustment, with research
factors which can influence social competence; suggesting that the ability to cognitively process
and (iv) strategies for integrating assessment socially-oriented information (i.e., social cogni-
into treatment. tion) is especially critical to success in inter-
personal spheres (Penn, Corrigan, Bentall,
6.08.3.1 Components of Social and Problem Racenstein, & Newman, 1997).
Solving Skills Third, after social perception and cognitive
skills have been used to appraise a situation and
Prior to the late 1970s, social skills were formulate a plan of action, behavioral skills are
broadly conceptualized strictly in terms of required to carry out the plan. Behavioral skills
specific behaviors such as eye contact, voice refer to the actual behaviors emitted in inter-
tone, and the verbal content of what is said. personal situations that are necessary to achieve
However, in the late 1970s and 1980s, a number a particular goal. Broadly speaking, behavioral
of different clinical research teams indepen- skills can be divided into four different areas,
dently proposed a tripartite typology of social including nonverbal components, paralinguistic
skills, which included social perception, cogni- skills, verbal content, and interactive balance.
tive (or problem solving) skills, and behavioral Nonverbal components are behaviors such as
skills (McFall, 1982; Morrison & Bellack, 1981; eye contact and use of gestures that convey
Trower, Bryant, & Argyle, 1978; Wallace et al., meaning or affect during an interaction. Para-
1980). Based on this broader conceptualization linguistic skills correspond to the vocal char-
of social skills, social competence is conceptual- acteristics of speech, such as voice tone,
ized as requiring three different types of skills. loudness, and inflection. Like nonverbal com-
First, in order to be effective in a social ponents, paralinguistic skills often communicate
situation, the person must be able to accurately vital information during an interaction, such as
perceive relevant situational parameters, such as the speaker's mood or underlying motives.
their relationship to the other person, whether Verbal content refers to what is actually said,
the setting is public or private, and the other regardless of the manner in which it is said. If the
person's affective response (i.e., social percep- verbal content is difficult to understand, bizarre,
tion skills). Recognition of these situational or socially offensive, it will interfere with social
features is crucial, as they may constrain the competence. However, in most day-to-day
appropriateness of social behaviors. There is interactions, nonverbal and paralinguistic skills
ample evidence showing that social perception are as important or more important than verbal
skills, such as the inability to accurately perceive content in determining a person's social effec-
the facial expressions of others or recognize tiveness. Interactive balance concerns the re-
interpersonal problems, are correlated with ciprocity between two individuals in a social
poorer role performance in clinical populations interaction. For example, the amount of time
(e.g., Bellack et al., 1994; Hellewell & Whittaker, each person spends speaking, and the amount of
1998; Mueser et al., 1996). reinforcement each speaker provides to the
Second, after the relevant social information other when the other person is speaking, can
has been extracted from a situation, the influence whether a person experiences an
individual must be able to formulate a goal, interaction as rewarding. Thus, the interactive
generate possible response alternatives for balance between two persons may partly
achieving the goal, weigh the benefits and determine whether either person desires similar
disadvantages of each possible solution, and interactions with the other in the future.
choose the best solution. Although these Numerous studies have documented that the
cognitive skills may occur implicitly, they have social behaviors emitted in interpersonal
an important bearing on the success of any plan, encounters, including paralinguistic features,
Assessment 187
nonverbal skills, verbal content, and interactive provide therapists with valuable insights into
balance, are less effective in clinical populations clients' perceptions of their own needs. Because
such as schizophrenia than in nonclinical of these distinct advantages, the assessment of
populations, and are correlated with social skills usually includes at least some information
functioning (e.g., Bellack, Morrison, Mueser, from the client's point of view. Although self-
Wade, & Sayers, 1990; Bellack, Morrison, report information is easily obtained, it often
Wixted, & Mueser, 1990). Table 1 provides a has limited validity, especially in clients with
summary of the different components of social severe mental illnesses such as schizophrenia
skills. and bipolar disorder. An additional problem is
that self-reports often lack the behavioral
specificity necessary to target specific situations
6.08.3.2 Assessment Strategies and behaviors for skills training. For these
A number of different strategies can be used reasons, self-reports are of limited utility in the
to assess social and problem solving skills, assessment of social and problem solving skills,
including self-report, reports by significant although they are frequently obtained as an
others, naturalistic observations, and role-play adjunctive measure.
tests (Liberman, 1982). Each of these strategies Reports by significant others offer a number
has advantages and disadvantages, and a of advantages over self-reports of social and
combination of strategies is preferable (Curran, problem solving skills. Significant others often
1979; Wallace, 1986). It is usually best in clinical directly experience the consequences of poor
practice to combine at least two or more skills in clients, and may be able to pinpoint
assessment strategies for identifying specific specific situations in which these skills are most
deficits in social and problem solving skills that prominent. For individuals with psychotic
will be the focus of subsequent training. disorders, reports by significant others also
Different assessment strategies are briefly have the advantage of not being susceptible to
described below, including the advantages and the cognitive distortions and denials often
disadvantages of each approach. present in persons with these illnesses. Despite
Self-report measures of social and problem these advantages, there are a number of
solving skills (e.g., Connor, Dann, & Twenty- limitations of these reports. Significant others
man, 1982; Rathus, 1973), based on either are privy to only certain types of social
questionnaires or interviews, have the advan- interactions, and are thus unable to inform
tage of being easy to administer and score. In about clients' skills in many other situations. In
addition, assessments are helpful because they addition, although significant others can often
identify situations in which clients experience
difficulty, their reports typically lack the level of
Table 1 Components of social skills. behavioral specificity necessary to target skills
for training. Therefore, reports by significant
Nonverbal behaviors others are often useful for identifying problem
Eye contact areas and specific situations in which clients
Facial expression experience difficulties, which can then be the
Posture focus of more fine-grained behavioral analysis.
Use of gestures After self-reports and reports by significant
Body orientation others have identified problematic social situa-
Interpersonal distance tions, detailed assessments of specific situations
Paralinguistic skills can be conducted through the use of naturalistic
Loudness
Tone
observations and role-play tests. Naturalistic
Pitch observations can be important sources of
Affect information for several reasons. First, by their
Rate of speech very nature such observations have a high
Clarity of speech generalizability to the social environment which
Duration of utterance clients face. Second, naturalistic observations
Verbal content can be easily performed in certain settings in
Verbal message which clinical staff have regular contact with
Choice of wording clients. Third, direct behavioral observations
Appropriateness of self disclosure provide information at a level of specificity
Interactive balance
Smoothness of turn-taking
necessary for targeting behaviors in skills
Use of social reinforcers (e.g., reflective listening training.
skills) Of course, there are also limits to the value of
Balance of time-talking naturalistic observations (Foster, Bell-Dolan, &
Burge, 1988). Only certain social situations can
be readily observed by others, and some and disadvantages, and a combination of

important situations are almost always unob- methods is optimal in most cases. Assessment
servable (e.g., intimate communications, offers usually begins with identifying general areas of
to use drugs or alcohol). A related problem is dysfunction based on interviews with clients and
that the behavior of some clients may be reactive significant others. Information gleaned from
to the presence of an observer, rendering the these interviews can then be used to specify
observation less naturalistic than intended. situations for more specialized assessment,
Despite these limitations, naturalistic observa- employing naturalistic observations and/or
tions provide important information about the role-play tests to better characterize the nature
social behavior of clients in ªreal worldº settings. of any behavioral deficits or excesses.
A final assessment method is the use of role-
play tests for the assessment of social skills. 6.08.3.3 Nonskill Factors which can Affect
Role-play tests involve the engagement of Social Competence
clients in a simulated interaction which may
be recorded and later rated on different Although social and problem solving skills
dimensions of social and problem solving skills. are hypothesized to be important determinants
There are several advantages of role-play tests of social competence and social functioning, not
over other assessment methods. Because role- all impairments in social adjustment are the
plays can be scripted to address specific problem result of deficits in these skills. The recognition
situations, they can be used to assess behavior of other factors which can also affect social
across a wide range of situations, including functioning is critical, since successful interven-
situations in which naturalistic behavior cannot tion may require attention to these factors in
ordinarily be observed. Because of the contrived addition to, or instead of, social skills. These
nature of role-play tests, the responses of factors fall under the general categories of
confederates can be scripted, permitting the medication side effects, mood, other psychiatric
comparison of a client's performance both with symptoms, environmental factors, and cultural
other clients as well as over time. A final mores.
advantage of role-play tests is that there is A number of medication side effects can
extensive research supporting both their relia- interfere with social functioning (Kane &
bility and validity. For example, role-play tests Lieberman, 1992). For example, akinesia is a
tend to be stable over time in the absence of side effect of antipsychotic medications, char-
social skills training, and are correlated with acterized by a diminution of facial expressive-
independent measures of more naturalistically ness and use of gestures. Another common side
observed social behavior as well as social role effect of antipsychotic medications is akathisia,
performance (e.g., Bellack et al., 1990; Mueser, reflected by an inability to sit still and a need to
Bellack, Douglas, & Morrison, 1991). pace. Both of these medication side effects can
Probably the most significant limitation of interfere with social functioning because they
role-play tests is the time and effort required to may either make it difficult for the client to be
administer them properly. Additional persons sufficiently expressive (akinesia) or have a
need to be trained and on hand to participate as distracting influence on social interactions
confederates in role-play tests or the therapist (akathisia).
must be able to serve as the partner. Depending Problems with mood, such as depression, may
on the rigor necessary for the rating of social result in clients not using social and problem
skills, extensive training may be necessary to solving skills that are in their behavioral
obtain reliable ratings of skill in role-play tests. repertoire. For example, positive affect has
Aside from the effort involved in conducting been experimentally demonstrated to facilitate
role-play tests, another limitation is the fact that creative problem solving (Isen, Daubman, &
role-plays tend to provide information about Nowicki, 1987). Depression, reflected by a sense
whether a client is capable of performing a of futility and hopelessness, may cause a person
requisite skill, but not necessarily whether he or not to use critical social or problem solving skills
she will perform that skill when an appropriate during an interaction, or to give up pursuing
situation arises. These limitations notwithstand- interpersonal goals altogether (Marx, Williams,
ing, role-play tests have been shown to be useful & Claridge, 1992). Anxiety can interfere with a
for assessing social skills across numerous person's ability to use skills that he or she is
studies, and are sufficiently sensitive to the ordinarily capable of, or may result in the
effects of social skills training to show improve- avoidance of situations relevant to achieving
ments consistent with predictions (Bellack, interpersonal goals. Similarly, intense feelings
1979, 1983). of anger or hostility may impede the ability of a
In summary, each of the different strategies client to use effective social and problem solving
for assessing social skills has both advantages skills.
Training Techniques 189
Other psychiatric problems may also con- for selecting target behaviors for intervention,
tribute to poor social competence independent ongoing assessment over the course of treat-
of social skill. One group of symptoms that can ment is critical for evaluating the success of
have a negative effect on social functioning is the intervention. Improvements in the specific
negative symptoms of schizophrenia, such as social and problem solving skills targeted for
blunted affect, anhedonia, asociality, and pau- treatment can be evaluated through the use of
city of speech (Andreasen, 1982). For example, role-play tests and naturalistic observations in
clients with a diminished capacity to experience some settings. The larger question of whether
pleasure (anhedonia) may fail to initiate inter- improved social and problem solving skills
actions or use relevant skills because they lack translate into better role functioning is best
the motivation to pursue personal goals (Blan- addressed through interviews with clients and
chard, Bellack, & Mueser, 1994). Another group significant others. More objective information
of symptoms that can interfere with social may be obtained through the selected use of
functioning are positive symptoms such as standardized instruments for evaluating social
hallucinations, delusions, and bizarre behavior. functioning.
Clients with prominent positive symptoms often
experience difficulties in their interpersonal
relationships because their tenuous contact with 6.08.4 TRAINING TECHNIQUES
reality interferes with establishing a common There are two basic models which are
ground of understanding, a necessary precondi- commonly used to train social skills: the motor
tion for much human communication (Chad- skills model and the problem solving model
wick, Birchwood, & Trower, 1996; Fowler, (Bellack, Morrison, & Mueser, 1989).
Garety, & Kuipers, 1995).
Environmental factors can have a profound
6.08.4.1 Motor Skills Model
impact on the likelihood that clients will use
skills that are in their behavioral repertoires. The primary focus of the motor skills model is
Similarly, environmental factors can also inter- on training the specific component skills
fere with the acquisition of skills during social necessary for successful interactions through
skills training, by either limiting the opportunity repetition and programming the generalization
clients have to use particular skills, or by not of skills to a variety of real-life situations (e.g.,
providing sufficient reinforcement for using the Bellack et al., 1997). The fundamental assump-
skills in appropriate situations. For example, in tion underlying the motor skills model is that
some state hospital settings, clients are rein- overlearning specific behavioral skills through
forced by staff for assuming the ªsick roleº (i.e., practice in both simulated (role play) and real
extremely passive behavior), and attempts to social situations will result in these skills
break out of this mold by more goal-directed becoming automatic in relevant situations.
behavior may be actively discouraged (Goff- Improved social competence, according to the
man, 1961; Wing & Brown, 1970). For another motor skills model, develops in a fashion similar
example, a depressed client who lives with a to the way in which expert performance
domineering spouse may be actively discour- develops over the course of extensive practice,
aged from becoming more assertive unless that resulting in complex skills that can be per-
spouse is involved in, understands, and accepts formed without contemplating the necessary
the treatment plan. steps in advance (Ericsson & Charness, 1994).
Finally, cultural mores can influence both
social skill and social competence. Cultures may 6.08.4.2 The Problem Solving Model
vary in the established norms for behavior based
on factors such as gender, age, and relationship The problem solving model also places
to others. Behavior deemed to be ªunassertiveº emphasis on the importance of repetition for
in one culture may be viewed as ªnormalº and acquiring necessary social skills. However,
desirable in another (Sue & Sue, 1990). Aware- according to this model, the generalization of
ness of the cultural norms of the groups to which social skills to novel situations requires cognitive
clients belong is critical in order to understand or problem solving skills to be maximally
cultural factors contributing to what appear to effective (e.g., Liberman et al., 1989). Real-life
be problems in social functioning. situations provide a multitude of different
challenges, not all of which can be anticipated
6.08.3.4 Integration of Assessment and and prepared for in advance. The basic thesis of
Treatment the problem solving model is that if clients are
able to systematically apply problem solving
Although the assessment of social and skills in order to formulate goals and deal with
problem solving skills serves as the cornerstone obstacles or problems in social situations, their
social competence will be improved. Thus, in although the basic techniques are the same when
addition to training motor skills, this model working with individuals.
incorporates problem solving training in order In order to teach a new social skill, a rationale
to improve the generalization of social skills to must first be established for the importance of
novel situations, to enable clients to overcome learning this skill. A combination of strategies
potential obstacles to achieving goals, and to can be used to develop the rationale, including
develop alternative strategies when initial ones asking questions in the Socratic style (e.g.,
fail. ªWhy might it be helpful to express a positive
feeling to someone who has just done something
6.08.4.3 Common Learning Principles for you?º), providing additional reasons for the
importance of a skill, and exploring the
Both the motor skills and problem solving relevance of the skill to clients' personal goals
models employ a common set of learning and circumstances. The therapist's most im-
principles, based mainly on instrumental (or mediate goal is to harness clients' motivation to
operant) and observational (or social) learning learn the new skill.
theories (Bandura, 1969; Skinner, 1938), to train After the importance of a skill has been
new social skills. Modeling (demonstrating a established, the therapist discusses the specific
skill in a role-play) is frequently employed to component steps of the skill. For example, the
familiarize clients with the basic steps of skill of ªexpressing negative feelingsº can be
targeted skills. Verbal reinforcement is gener- broken down into the following five component
ously used to encourage effort and to draw behaviors: (i) look at the person; (ii) speak in a
attention to particular component skills that firm voice tone; (iii) tell the person what they did
were performed well in a role-play situation. to upset you; (iv) tell them how it made you feel;
Shaping refers to the reinforcement of (v) suggest how this can be prevented from
successive approximations to a goal. Social happening again in the future. The importance
skills require the complex integration of a of each component step of the skill is discussed
number of component skills. Typically, these (e.g., it is important to look at the person so that
skills are learned gradually over many role-plays you can be sure that you have their attention
and with much practice outside of the sessions. when you speak to them). After discussing the
Therefore, in order to encourage clients to keep different steps of the skill, the therapist
trying, and to recognize their progress in demonstrates the skill in a role-play. Role-plays
acquiring targeted component skills, behavior are planned in advance, are usually quite brief,
needs to be shaped gradually over time by and are based on situations that are both highly
providing ample reinforcement along the way. plausible and likely to be encountered by clients.
Generalization is the ability to transfer a skill Immediately following the role-play, the thera-
learned in one setting to another situation. In pist obtains feedback from clients about which
order for social skills training to improve social component steps of the skill were observed and
functioning, clients must be able to use the skills the overall effectiveness of the therapist in the
acquired in training sessions in real-life settings. role-play.
Therefore, programming the generalization of When clients have had an opportunity to
skills to client's natural living environments is observe the therapist model the skill, one client
an integral part of social skills training. Some of is engaged in a role-play of the same skill,
the strategies employed to facilitate general- usually based on the same situation. The
ization include community trips for clients to advantage of using the same role-play situation
practice skills on their own, homework assign- at this point of the training is that it minimizes
ments, and teaching significant others (e.g., the amount of work the client must do in order
family members, staff members) to prompt to achieve a successful performance. Immedi-
clients to use skills in appropriate situations. ately following the role-play, the therapist
provides positive feedback to the client about
6.08.4.4 Basic Skills Training Techniques which specific steps of the skill were performed
well. A critical feature of social skill training is
The basic techniques of social skills training that the therapist always provides immediate,
are outlined in Table 2 and are summarized positive, and specific feedback following each
briefly here. More information about techni- role-play. This feedback serves to encourage
ques for training social skills are available in a clients' efforts for trying to perform the skill as
variety of books, including McFall (1976), well as specific reinforcement for behaviors that
Trower et al. (1978), Goldstein (1982), Kelly were done especially well.
(1982), Hargie and McCartan (1986), Liberman After positive feedback has been provided,
et al. (1989), and Bellack et al. (1997). The table the therapist provides the client with corrective
describes social skills training in a group format, feedback, conveyed in a helpful, upbeat manner.
Table 2 Steps of social skills training.
1. Establish rationale for the skill

. Elicit reasons for learning the skill from group participants
. Acknowledge all contributions
. Provide additional reasons not mentioned by group members
2. Discuss the steps of the skill
. Break the skill down into three or four steps
. Write the steps on a board or poster
. Discuss the reason for each step
. Check for understanding of each step
3. Model the skill in a role-play
. Explain that you will demonstrate the skill in a role-play
. Plan out the role-play in advance
. Use two leaders to model the skill
. Keep the role-play simple
4. Review the role-play with the participants
. Discuss whether each step of the skill was used in the role-play
. Ask group members to evaluate the effectiveness of the role model
. Keep the review brief and to the point
5. Engage a client in a role-play of the same situation
. Request the client to try the skill in a role-play with one of the leaders
. Ask the client questions to make sure he or she understands their goal
. Instruct members to observe the client
. Start with a client who is more skilled or is likely to be compliant
6. Provide positive feedback
. Elicit positive feedback from group members about the client's skills
. Encourage feedback that is specific
. Cut off any negative feedback
. Praise effort and provide hints to group members about good performance
7. Provide corrective feedback
. Elicit suggestions for how client could do the skill better next time
. Limit the feedback to one or two suggestions
. Strive to communicate the suggestions in a positive, upbeat manner
8. Engage the client in another role-play of the same situation
. Request that the client change one behavior in the role play
. Check by asking questions to make sure the client understands the suggestion
. Try to work on behaviors that are salient and changeable
9. Provide additional feedback
. Focus first on the behavior that the client was requested to change
. Engage client in two to four role-plays with feedback after each one
. Use other behavior shaping strategies to improve skills such as coaching, prompting, and
supplemental modeling
. Be generous but specific when providing positive feedback
10. Assign homework
. Give an assignment to practice the skill
. Ask group members to identify situations in which they could use the skill
. When possible, tailor the assignment to each client's level of skill
Rather than providing negative feedback about When corrective feedback has been provided,
component skills that were performed poorly, the client is engaged in a second role-play with
one or two suggestions are made for how the specific instructions to modify particular com-
client could improve his or her performance in ponent behaviors. The same role-play situation
another role-play. In addition to giving verbal is used as in the first role-play. The second role-
suggestions for how to improve performance in play is followed by the same sequence of positive
the next role-play, the therapist can also model specific reinforcement, with initial emphasis on
the skill again, drawing the client's attention to the component skills targeted for change,
specific component behaviors that are targeted followed by corrective feedback. Typically, a
for change. client can be engaged in two to five role-plays of a
skill, depending on his or her motivation and perform the skill spontaneously in real-life
improvement over the role-plays. If verbal situations, additional skills are introduced and
instructions and praise alone are insufficient to trained.
bring about behavior change in the role-plays,
the therapist may use a variety of other teaching 6.08.4.5 Problem Solving Training
techniques such as supplemental modeling by
the therapist, coaching (i.e., whispering verbal As in social skills training, training in
prompts to the client during a role-play), problem solving skills involves following a
prompting (i.e., providing the client with nonspecific sequence of steps (D'Zurilla & Gold-
verbal cues, such as hand signals, to modify his or fried, 1971). These steps are designed to allow
her behavior during a role-play) (Bellack et al., consideration of as many solutions as possible
1997), or, for severely impaired clients, attention and to consider what is needed in order to put a
focused training (i.e., combining verbal cues for chosen plan into action. While social skills
response with primary reinforcers such as food) training focuses on teaching specific component
(Massel et al., 1991). The most critical concern behaviors necessary for effective interactions,
when engaging a client in a series of role-plays is problem solving training aims to teach a process
that he or she demonstrates some improvement for approaching problems and achieving goals.
in the targeted skill from the first to the last The process of problem solving has been likened
behavioral rehearsal. This is the essence of the to the scientific method (Kuhn, 1970; Popper,
shaping process, in which role-plays provide 1979), in which the essential task is to educate
learning opportunities to improve performance clients how to think and approach psychological
over multiple trials. problems in a more systematic, rational, and
After sufficient progress has occurred over empirically based manner (Beck, 1976; Ellis,
the role-plays (and other clients have had the 1962). Thus, while social skills training tends to
opportunity to practice the skill in similar role- be content-oriented, training in problem solving
plays), the therapist develops a homework is oriented towards teaching a set of processing
assignment for clients to practice the skill on skills designed to maximize goal attainment.
their own. The rationale for practicing the skill The basic steps of problem solving are
outside of the session may need to be reviewed outlined in Table 3 and are briefly described
with the client. Homework assignments are here. Further information about problem
most effective when a specific situation to solving training can be found in a variety of
practice the skill can be identified by the client books and book chapters, including Falloon,
and therapist in advance. Possible obstacles to Boyd, and McGill (1984), D'Zurilla (1986),
completing the assignment should be antici- Hawton and Kirk (1989), Nezu, Nezu, and Perri
pated. When possible, significant others should (1989), and Mueser and Glynn (1995). The same
be informed of the homework assignment so steps of problem solving listed in the table are
they may remind or prompt the client to practice followed when teaching in an individual, group,
the skill in appropriate situations. couple, or family format.
The preceding sequence describes the intro- Prior to the initiation of problem solving
duction of new skills in social skills training. training, the therapist endeavors to develop in
Usually several sessions are spent teaching one clients a problem solving ªorientationº in which
specific skill before moving onto another skill. problems are viewed as obstacles which can be
Following the introduction to a skill, subse- overcome or improved upon by systematically
quent sessions begin with a review of home- exploring and trying different response options.
work, including the identification of situations Similarly, achieving short- and long-term goals
where the client has unsuccessfully tried to use is construed as requiring individuals to over-
the skill or could have used the skill but did not. come a series of obstacles which are ordered in
Instead of getting a description from the client logical sequence. The development of a problem
of what happened, the therapist engages him or solving orientation can be facilitated by provid-
her in setting up the role-play of that situation. ing examples of problems and their solutions,
Following the role-play, positive and corrective and reviewing the steps of problem solving.
feedback are provided using the principles However, in the long-run, clients learn to adopt
previously described. Role-plays from more a problem solving orientation through repeated
than one situation can be practiced, as well as prompting, practicing the steps of problem
situations that the client expects to encounter or solving on personally relevant problems, and
hypothetical situations. Practicing the targeted experiencing the natural consequences of im-
skill across a variety of role-play situations, as plementing effective solutions to their problems.
well as trying the skill in real-life situations, Problem solving begins with the identification
serves as a form of generalization training. of a problem or goal that the client wishes to
When the client has demonstrated an ability to resolve or achieve. As the definition of the
Table 3 Steps of problem solving.
Step 1: Define the problem

. Get different opinions about the nature of the problem
. Define the problem or goal in behaviorally specific terms
. If the problem is shared by more than one person, make sure each one agrees on the definition
Step 2: Generate possible solutions to the problem
. Brainstorm as many different solutions as possible
. Do not evaluate any solutions at this time
. Be creative and include ªwild and crazyº ideas
Step 3: Evaluate the solutions
. Consider the advantages and disadvantages of each solution for solving the problem
. Systematically evaluate one solution at a time
. Avoid settling on one ªbestº solution before reviewing all solutions
Step 4: Select the best solution(s)
. Select the solution that seems most likely to be effective
. Consider how difficult the solution will be to implement
. Choose more than one solution if they can be easily combined
Step 5: Plan on how to implement the solution(s)
. Consider what resources are needed to implement the solution (e.g., money, skills, information)
. Anticipate possible obstacles to implementing the solution
. Establish a time frame for implementing the solution(s)
. If more than one person is involved, establish specific tasks for each person
Step 6: Review problem solving plan at a later time
. Plan a time to evaluate whether the problem solving plan was successful
. Do additional problem solving and modify the plan if the desired goal has not been obtained
. Praise all efforts at solving the problem, even if the problem is not entirely resolved
problem is crucial to the solutions that will be ing, or evaluating any of the solutions that come
generated and likely success of solving it, the to mind. Instead, all solutions are acknowl-
problem should be discussed in detail, and edged, with the expectation that suggesting even
questions should be posed such as ªWhy is it a bad or inappropriate solutions may lead to the
problem?,º ªFor whom is it a problem?,º and identification of novel and innovative strategies.
ªHow have you tried to solve this problem in Clients who tend to be overly self-critical and
the past and what happened?º If problem punitive may require extra practice at not
solving is conducted with others who may be immediately rejecting solutions as soon as they
invested in the problem and its solution (e.g., are generated.
family members), then multiple perspectives After a variety of possible solutions have been
on the problem are sought to ensure each identified, each one is systematically evaluated
person's involvement. When the nature of the in terms of its perceived effectiveness for solving
problem or goal has been considered, the client the problem. This evaluation can be standard-
must arrive at a specific definition of the ized by routinely assessing the advantages and
problem. In general, the more behaviorally disadvantages of each solution. Following the
specific the definition, and the more circum- evaluation of solutions, the best solution or
scribed the problem, the greater the chance of combination of solutions is selected. Often, the
solving the problem. Large, complex problems best solution is quite evident after the advan-
and ambitious goals are best approached by tages and disadvantages of each solution have
breaking them into smaller, more manageable been considered. Sometimes no one solution is
chunks, each of which is the focus of problem obviously best, more than one solution appears
solving. For couple- and family-based problem equally effective, or, when more than one
solving, all involved persons must agree on the person has a stake in the problem, there is
definition of the problem in order for them to be disagreement as to the ªbestº solution. In such
involved in its resolution (Falloon et al., 1984). cases, the best solution is determined by
When a problem or goal has been articulated, combining different solutions, selecting more
multiple solutions are identified for solving the than one solution to implement, and determin-
problem or achieving the goal. Clients are urged ing which one should be tried first, or creating a
to be as creative as possible at this point of new solution drawn from the previously
problem solving, and to avoid editing, censur- discussed ones.
Solutions to problems can only be effective if solutions) for solving the problem. When a
they are implemented. Furthermore, a variety of different solution has been selected, a new
obstacles can conspire to interfere with the implementation plan must be made. If every
implementation of a potentially effective solu- solution has been tried and implemented, but
tion to a problem. Therefore, planning on how the problem remains, the third step is to
to implement the solution is critical to successful generate additional solutions for resolving the
resolution. Several factors are useful to consider problem or achieving the goal, to then evaluate
when determining a plan for solving the these new solutions, select the best one, and plan
problem. First, if more than one person is on how to implement it. Finally, if repeated
involved in solving the problem, roles for attempts at solving a problem are unsuccessful
implementing the solution need to be agreed and all viable solutions have been exhausted, a
upon. Second, the resources needed to imple- fourth and last step is to define the problem
ment the solution must be evaluated, such as differently in order to increase the probability
money, expertise, information, or skills. Role- that the new problem will be more solvable than
plays may be useful at this stage to help clients the old one.
develop or practice the requisite skills for
enacting a solution. Third, possible obstacles
to effective implementation should be explored 6.08.5 FORMAT OF SOCIAL SKILLS AND
and, if realistic obstacles are identified, tentative PROBLEM SOLVING TRAINING
plans for dealing with them should be deter-
Social and problem solving skills can be
mined. Finally, a time-frame should be estab-
taught in a variety of formats, ranging from
lished for putting the different steps of the
individual psychotherapy, to group therapy, to
solution into action. This time-frame should
couples or family therapy.
include a follow-up time during which the
success (or lack thereof) of the problem solving
plan can be reviewed. 6.08.5.1 Group Skills Training
Although some problems are solved after a
single attempt at problem solving, many are not, The group format is one of the most common
and it is common for repeated efforts to be formats for teaching social and problem solving
required to make sufficient progress at resolving skills. Skills training in groups generally follows
a problem or achieving a goal. An important a preplanned curriculum, which is provided
part of developing in clients a problem solving over a limited time period, ranging from several
orientation is conveying the idea that problem months to over a year. Clients usually begin
solving is often an iterative process that requires participating in the group at its initiation, and
multiple efforts in order to secure success. In continue until the targeted skills have been
order to ensure that problem solving continues acquired. Groups are often led by two therapists
to be applied to problems that remain unsolved, and comprise clients with deficits in similar
it is helpful to establish follow-up times to areas.
evaluate the status of the problem or goal. There are several advantages to teaching
If the problem has been successfully resolved, social skills and problem solving in a group
then a new problem or goal can be targeted. On format. First, there is the obvious advantage of
the other hand, if the problem remains, the economy, considering that one or two therapists
therapist teaches the client how to system- can work with five to eight clients simulta-
atically ªdebugº the problem solving plan. neously in a group setting. Second, group-based
Finding the problem in a problem solving plan skills training provides clients with a variety of
is accomplished by going through the steps of different role models, which may facilitate their
the plan in reverse order until a problem with the acquisition of targeted skills. Third, feedback
plan is identified, at which point the problem in from other clients can be obtained in a group
the plan is corrected, and any necessary changes format, providing additional reinforcement for
in the following steps are determined (Mueser & clients to practice the requisite skills. Fourth,
Glynn, 1995). Thus, the first step in debugging a group-based skills training can provide the
problem solving plan is to determine if the opportunity for role-playing with a variety of
solution was implemented as intended. If it was different partners (i.e., different clients), a task
not, then the implementation plan needs to be which is much more difficult to accomplish
altered in order to determine whether the when conducting individual psychotherapy.
selected solution will work. If the solution Fifth, clients often appreciate the opportunity
was implemented, but it did not work and the of working with others who share similar
problem remains, then the second step is to re- difficulties and goals. For example, group-based
evaluate the other possible solutions, and social skills training can be conducted with
choose a different solution (or combination of individuals with severe mental illnesses (e.g.,
Clinical Applications and Research 195
schizophrenia), social phobia, or poor asser- dures used in the group format for teaching
tiveness skills. Problem solving training in a social skills, and are then given homework
group format offers the same advantages. assignments to practice these skills on their own.
Clients often enjoy being able to help each Role-plays are used to assess family members'
other make progress towards desired goals and acquisition of targeted skills. When family
appreciate knowing that they are not alone in members have demonstrated improvements in
the problems or obstacles they face. In addition, basic communication skills, they are then taught
since most problems or goals that clients have problem solving skills. Initially, the therapist
are not unique, more than one client may benefit leads the family to demonstrate the steps of
from progress made on problem solving about a problem solving. Subsequent to this, family
particular goal. members elect their own ªchairmanº to lead the
problem solving discussion and ªsecretaryº to
6.08.5.2 Individual Format record the family's problem solving efforts. The
members are encouraged to have weekly meet-
Although the group format for skills training ings to practice their problem solving skills.
has a number of advantages, it is often not Over time, as the family members' skills
practical, especially for clinicians working in improve, increasingly more difficult problems
private practice. Social skills and problem are tackled, including problems that may be
solving training in an individual format follows the source of major conflict between family
the same basic principles as when working with members.
groups. There are several advantages to It is also possible to combine the group and
individual-based work. By its very nature, it is family formats into a multiple family group
easier to tailor treatment sessions to the specific format. For example, McFarlane (1990) has
needs presented by the client. There is also more developed a model of multiple family group
time for training skills because of the exclusive intervention for persons with schizophrenia and
focus on one client. Finally, skills training can their relatives. In groups that are held every two
be conducted on an ad hoc basis, rather than weeks, problem solving is taught and regularly
following a structured curriculum, which may practiced in order to identify effective solutions
be more beneficial for some clients participating to common problems, thereby reducing the risk
in other types of psychotherapy, such as of relapse and rehospitalization (McFarlane
cognitive restructuring or relaxation training. et al., 1995).
6.08.5.3 Family Format

6.08.6 CLINICAL APPLICATIONS AND
Social skills and problem solving training can RESEARCH
be conducted in the context of family or couples
intervention. For example, behavioral marital Social skills and problem solving training
therapy typically incorporates both training in have been applied to very wide range of
basic communication skills for couples and psychiatric disorders and interpersonal difficul-
problem solving skills as a strategy for mini- ties. In fact, there are few areas of psycho-
mizing conflict and increasing positive interac- pathology or interpersonal dysfunction for
tions (e.g., Bornstein & Bornstein, 1986; which skills training approaches have not been
Jacobson & Margolin, 1979; Liberman, Wheel- developed. For example, skills training ap-
er, deVisser, Kuehnel, & Kuehnel, 1980). These proaches have been developed to help people
interventions are based on the assumption that with problems such as anger management,
most of the difficulties maritally distressed interpersonal shyness and dating anxiety, poor
couples experience are due to deficits in assertiveness, conflict resolution, difficulties
communication rather than fundamental differ- with interpersonal relationships on the job,
ences in values and preferences. marital discord, and dealing with social situa-
Similarly, behavioral family therapy involves tions involving substance abuse. Although
teaching basic communication skills and prob- social and problem solving skill interventions
lem solving skills to family members (Mueser & generally focus on improving interpersonal
Glynn, 1995). For example, Falloon, Boyd, and competence in specific domains of functioning,
McGill (1984) developed a model in which programs are often targeted at groups of clients
families are taught four basic communication with specific diagnoses, including major depres-
skills (active listening, expressing positive feel- sion, schizophrenia, borderline personality dis-
ings, making positive requests, expressing order, and social phobia, as well as individuals
negative feelings), followed by the six steps of with developmental disabilities.
problem solving. Families are taught commu- Table 4 summarizes clinical applications of
nication skills following the same basic proce- social and problem solving skills training to
different problem areas and populations. Many social and problem solving skills training, such
of the programs described in this table have been as cognitive therapy and scheduling pleasant
empirically validated in controlled studies. The events (Dobson, 1989; Zeiss, et al., 1979).
research literature supporting the efficacy of Therefore, skills training can be used as a
social and problem solving training has grown primary treatment approach for depression,
rapidly over the last two decades, and these although its effects can be expected to be similar
approaches now enjoy some of the best to those of other psychological interventions. In
empirical support of all psychological interven- clincal practice, skills training is most often
tions. It is beyond the scope of this chapter to provided as an adjunctive intervention for some
critically review research on the effects of social clients, in combination with cognitive or inter-
skills training and problem solving training. personal therapy, rather than as the sole
However, numerous books and review articles intervention.
are available that critically evaluate these Similar in some respects to its use in major
different training programs, including Bedell depression, social skills training is frequently
and Lennox (1996), O'Donahue and Krasner employed as an adjunctive strategy in the
(1995a), Dilk and Bond (1996), Benton and treatment of social phobia. For example, in a
Schroeder (1990), Nezu and Nezu (1989), and program for social phobia developed by Heim-
Smith, Bellack, and Liberman (1996). berg et al. (1990), cognitive therapy and
exposure are combined with social skills train-
ing (role playing) in order to provide clients with
6.08.6.1 Utility of Social and Problem Solving feedback about their behavior, to challenge
Skills Training their distorted perceptions about their own
social behavior, and to encourage them not to
From a treatment planning perspective, it is avoid feared social situations. Although some
important to consider when skills training is a research suggests that cognitive therapy may
treatment on its own and when it best serves as an not reduce social anxiety above and beyond that
adjunct to other approaches to therapy. To some provided by the combination of social skills
extent, the answer to this question depends on training and exposure (Hope, Heimberg, &
whether skills training is used to treat a complex Bruch, 1996; Stravynski & Shahar, 1983), other
constellation of behaviors and symptoms (e.g., a research indicates that cognitive therapy alone
psychiatric disorder) or a more specific and may be effective (Emmelkamp, Mersch, Vissia,
narrower class of situations and behaviors. & van der Helm 1985). However, in practice no
There have been numerous controlled studies single treatment approach is usually provided
of skills training for schizophrenia, with some for social phobia; rather, most treatment
evidence documenting benefits in the areas of programs involve a combination of strategies,
social functioning, symptom severity, and including social skills training, exposure, and
relapses and rehospitalizations (e.g., Bellack, cognitive therapy (e.g., Heimberg et al., 1990;
Turner, Hersen & Luber, 1984; Hogarty et al., Turner, Beidel, & Cooley, 1994).
1991; Marder et al., 1996). Schizophrenia is a Social and problem solving skills training can
complex illness involving impairments across be effective as treatments on their own (or in
multiple domains, including social adjustment, combination with training in other self-regula-
cognitive functioning, and symptomatology. tory skills, such as stress inoculation, relaxation,
When skills training is conducted with persons cognitive restructuring) when they are provided
with schizophrenia, it is provided in the context to address a specific problem (or class of
of a comprehensive treatment program (Bellack problems), often within a specific population
& Mueser, 1993), which may include a veriety of (e.g., clients with developmental disabilities,
other interventions such as medication and psychiatric disorders). There are numerous
symptom monitoring, case management, family studies in the research literature (some included
psychoeducation, and vocational rehabilitation. in Table 4) of skills training interventions
With respect to major depression, both social demonstrating superior outcomes compared
skills training and problem solving training have with other treatment or waitlist (no treatment)
been shown to be effective in reducing severity of comparison groups. For example, skills training
depression without the use of other interventions has been found to be useful in decreasing
(Bellack, Hersen, & Himmelhoch, 1983; Nezu & problems related to anger (Benson, Rice, &
Perri, 1989). However, in contrast to schizo- Miranti, 1986; Deffenbacher, 1988), improving
phrenia, where relatively few psychological social anxiety, loneliness, and dating skills (e.g.,
interventions have been established to be Fox, McMorrow, Storey, & Rogers, 1984;
clinically effective, a wide variety of therapeutic MacDonald, Lindquist, Kramer, McGrath, &
approaches appear to result in improvements in Rhyne, 1975), improving assertiveness (Gam-
depression comparable to those produced by brill, 1995), enhancing job-related skills, such as
Table 4 Examples of clinical applications of social and problem solving skills training.
Program developers Target population Training format Focus of traininga
Alberti and Emmons (1990) Unassertive persons Group SST for skills to help people ªstand up for their rightsº and express feelings
directly
Becker, Heimberg, and Bellack (1987) Persons with depression Individual SST for interpersonal skills
Benson (1991) Mentally retarded adults Group SST and PS to teach strategies for managing anger and interpersonal conflict
Falloon et al. (1984) Families of persons with severe Family SST for basic communication skills and PS to help families solve problems and
Miklowitz and Goldstein (1997) psychiatric disorders achieve goals
Mueser and Glynn (1995)
Fisher and Carstensen (1990) Elderly nursing home residents Group SST to improve conversational and other social skills in elderly persons
Heimberg et al. (1990) Socially anxious clients Group Exposure to social situations, cognitive restructuring, and SST for peer intentions
Jacobson and Margolin (1979) Maritally distressed couples Couples SST for communication skills and PS to address problem areas
Kelly (1995) Persons with high HIV risk Group SST to reduce HIV risk behaviors
behavior
Kleiner, Marshall, and Spevack (1987) Agoraphobics Individual PS and exposure to feared situations
Liberman et al. (1989) Clients with schizophrenia Group (can be SST for communication skills, resolving conflicts, making friends, dealing with
Bellack et al. (1997) adapted for care providers, recreational and leisure activities
individuals)
Linehan (1993) Borderline personality disorder Group and SST and PS to address interpersonal skills, emotion regulation, and distress
clients individual tolerance
Maiuro (1991) Domestically violent men Group PS to reduce domestic violence
Monti et al. (1989) Alcoholics Group SST for conversational skills, expressing feelings, dealing with alcohol-related
situations
Mynors-Wallis, Davies, Gray, Primary care clients Individual PS to address anxiety and depression problems interfering with functioning
Barbour, and Gatz (1997)
Nezu, Nezu, and Perri (1989) Persons with major depression Individual PS to address interpersonal problems and goals related to depression
Novaco(1975) Persons with anger problems Individual Stress management skills, PS to identify suitable alternatives in conflict
situations, SST for dealing with provoking situations
Salkovskis, Atha, and Storer (1990) Suicidal persons Individual PS to identify problems and arrive at solutions that are alternatives to self-
injurious behaviors
Valenti-Hein and Mueser (1990) Mentally retarded adults Group SST and PS to develop dating skills (e.g., conversational skills, asking for a date,
resisting persuasion)
Waldo, Roath, Levine, and Freedman Mothers with schizophrenia Group SST to teach parenting skills
(1987)
Wong and Woolsey (1989) Chronic psychotic inpatients Individual SST to re-establish conversational skills in severely impaired clients
a
SST = social skills training; PS = Problem solving training.
interviewing, managing interactions with super- practice in social skills training. New York: Plenum.
visors, and peer relationships (e.g., Hughes & Bellack, A. S., Hersen, M., & Himmelhoch, J. M. (1983). A
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Bulletin, 15, 101±116.
problem solving skills training are most often Bellack, A. S., Morrison, R. L., Mueser, K. T., Wade, J.
combined with other therapeutic modalities H., & Sayers, S. L. (1990). Role play for assessing the
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K. T. (1990). An analysis of social competence in
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the most widely practiced interventions for the (1994). An evaluation of social problem solving in
treatment of psychological disorders in adults. schizophrenia. Journal of Abnormal Psychology, 103,
Therapies designed to improve social and 371±378.
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(1984). An examination of the efficacy of social skills
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adaptive interpersonal and self-management Community Psychiatry, 35, 1023±1028.
skills, and that these skills are most effectively Benson, B. A. (1991). Teaching anger management to
taught in a systematic fashion, employing the persons with MR/DD. Worthington, OH: IDS Publish-
principles of social learning theory. Training in ing.
Benson, B. A., Rice, C. J., & Miranti, S. V. (1986). Effects
social and problem solving skills can be of anger management training with mentally retarded
conducted in a variety of different formats, such adults in group treatment. Journal of Consulting and
as with individuals, groups, couples, or families. Clinical Psychology, 54, 728±729.
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6.09
Arousal Reduction Methods:
Relaxation, Biofeedback,
Meditation, and Hypnosis
GRAHAM C. H. TURPIN and MICHAEL HEAP
University of Sheffield, UK

6.09.2 A THEORETICAL OVERVIEW OF AROUSAL DYSFUNCTION AND AROUSAL MODIFICATION
INTERVENTIONS 204
6.09.2.1 Arousal as a Hypothetical Construct 204
6.09.2.2 Arousal Dysfunction and Health 206
6.09.2.3 Theoretical Basis of Arousal Modification Methods 208
6.09.2.4 Summary 210
6.09.3 AROUSAL REDUCTION METHODS: GENERAL PROCEDURES AND SPECIFIC TECHNIQUES 210
6.09.3.1 General Procedural Issues 211
6.09.3.1.1 Assessment 211
6.09.3.1.2 Therapeutic rationale 211
6.09.3.1.3 Practical considerations 212
6.09.3.1.4 Presentation of the technique 212
6.09.3.1.5 Evaluation of procedural factors 212
6.09.3.2 Specific Techniques 213
6.09.3.2.1 Relaxation-based methods 213
6.09.3.2.2 Biofeedback 214
6.09.3.2.3 Meditation 215
6.09.3.2.4 Hypnosis 215
6.09.3.3 Indications, Side Effects, and Contraindications 216
6.09.3.3.1 Client selection 216
6.09.3.3.2 Side effects and adverse reactions 217
6.09.3.3.3 Contraindications and procedural modifications 217
6.09.4 COMPARATIVE OUTCOMES AND THERAPEUTIC MECHANISMS 219
6.09.4.1 Overview of Outcomes 219
6.09.4.2 Therapeutic Mechanisms 221
6.09.1 INTRODUCTION and are also frequently associated with more

serious mental health problems such as panic,
Heightened arousal, elevated somatic tension, obsessional disorders, and psychosis. It is
increases in anxiety and worry, are common not surprising, therefore, that some of the
consequences of many everyday life experiences, earliest proposed psychological treatments (e.g.,
203
204 Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis
Jacobson, 1938), have targeted arousal reduc- pies, and what proportion of therapists
tion. Indeed, many of these techniques (e.g., identified within Eisenberg et al.'s survey are
meditation, hypnosis) have their origins in clinical psychologists? Many of these questions
nonscientific or religious practices and customs. go far beyond the scope of this chapter, since it is
Because of this, relaxation, biofeedback, med- our intention to focus only on those specific
itation, and hypnosis are frequently regarded, therapies that are delivered as part of a formally
particularly within the USA, as alternative or constructed and scientifically evaluated package
complementary therapies within medicine and of psychological treatment. Nevertheless, clin-
are provided by specialist practitioners such as ical psychologists have to be aware of a wider
stress counsellors, hypnotherapists, and bio- context, whereby clients and their referral
feedback practitioners. A recent review of sources already have access to and are familiar
ªunconventional medicineº practised within with these treatments, and which goes far
the USA (Eisenberg et al., 1993) revealed, by beyond that formally delivered within a clinic
means of a telephone survey of 1539 adults, that setting. It is likely, therefore, that such experi-
one in three respondents reported using at least ences may well influence how the efficacy and
one unconventional therapy in the past year, appropriateness of many of these therapies are
and a third of these had engaged in an average of judged, irrespective of any formal scientific
19 visits to a practitioner. Extrapolating from evaluation of their effectiveness.
this pattern of contact to the entire population, The major aims of this chapter, therefore, are
the authors concluded that the extent of usage of to overview therapeutic techniques directed at
unconventional therapies exceeded the number modifying arousal and inducing relaxation. The
of primary care consultations and the economic therapeutic rationales underlying these techni-
cost ($13.7 billion) was comparable to out-of- ques will be critically examined, together with
pocket expenditure for all hospitalizations an evaluation of their efficacy. The review will
within the USA. Relaxation (13%), chiropracty restrict itself primarily to adults and to problems
(10%), and massage (7%) accounted for the broadly conceived as being associated with
most frequently used therapies, and back mental health. Some reference, however, will be
problems (36%), anxiety (28%), headaches made to physical health and behavioral med-
(27%), chronic pain (26%), and cancer (24%) icine when reviewing more contemporary
represented the most common health problems applications. We will conclude by attempting
for which people had sought unconventional to appraise whether any common process or
therapies. Although reliance on a telephone mechanism might underlie change brought
survey may have overestimated the prevalence about by the application of these diverse
of these techniques, Eisenberg et al. (1993, psychological treatments.
p. 251) conclude that these therapies have ªan
enormous presence in the US health care
system.º They further concluded that they 6.09.2 A THEORETICAL OVERVIEW OF
represent a sizeable expenditure in healthcare, AROUSAL DYSFUNCTION AND
are used largely as adjuncts to conventional AROUSAL MODIFICATION
medical interventions, and are commonly INTERVENTIONS
undertaken independently of consultation with
A fundamental assumption that underlies this
the medical practitioner responsible for con-
chapter is that elevated ªarousalº is associated
ventional treatment of the presenting problem.
with a variety of mental and physical health
The above review included a wide range of
problems, and that treatment methods targeted
treatments unrelated to the focus of this
at ªarousalº reduction will alleviate the severity
particular chapter. Nevertheless, relaxation
of these conditions. Before we review these
(13%), imagery (4%), biofeedback (1%), and
proposed treatments, it is important that this
hypnosis (1%) were reported as being widely
assumption is examined further. The critical
used within a 12-month period for a range of
questions are: what is arousal, what associations
psychological problems (e.g. anxiety, depres-
exist between elevated arousal and physical and
sion, insomnia, and headache) which are
mental health problems, what techniques exist
frequently referred to a clinical or health
to modulate arousal, and what are the mechan-
psychologist, and this raises a number of
isms that mediate therapeutic change?
intriguing questions. For example, what is the
efficacy of these techniques, how severe are the
problems for which these therapies are com- 6.09.2.1 Arousal as a Hypothetical Construct
monly employed, how effectively are these
therapies delivered, what training and levels The construct of arousal has been revisited
of competence are associated with the practi- extensively within the literature, with respect to
tioners responsible for delivery of these thera- psychophysiology (Andreassi, 1989; Cacioppo
Theoretical Overview of Arousal Dysfunction and Arousal Modification Interventions 205
& Tassinary, 1990; Gale & Eysenck, 1992), ªemotion,º and ªanxiety,º and would be
emotion (Tucker, Vannatta, & Rothlind, 1990; severely limited without the explanatory power
Wagner, 1988), and clinical applications (Ca- that such constructs bestow on clinical for-
cioppo, Berntson, & Anderson, 1991; Lader, mulations and conditions. Indeed, we suggest
1975; Turpin, 1989, 1990; Wieisse, Davidson, & that arousal has important clinical utility and
Baum, 1989). A variety of different arousal that its use can be progressed by treating it in a
constructs can be identified, including arousal similar fashion to other clinical constructs such
as central nervous system activation underlying as anxiety. Just as anxiety is best conceptualized
an ªarousal±sleepº continuum (e.g. Duffy, according to Lang's three-system model (Lang,
1951), arousal as a general drive system 1968; Turpin, 1991), arousal might be broken
affecting behavior as characterized by the down into three component systems: physiolo-
inverted U model (e.g. Andrew, 1974; Claridge, gical, cognitive, and behavioral (Schilling &
1987), and arousal as a psychophysiological Poppen, 1983). Physiological arousal compo-
construct identified by peripheral physiological nents will include both central activation and
response patterning (e.g., Lacey, 1967). autonomic responding; cognitive components
Despite the almost ubiquitous presence of the might refer to both subjective experience and
ªarousal constructº within psychophysiology, verbal report, together with attentional con-
its current usage has markedly declined. Its sequences in terms of vigilance and selective
demise can be traced to Lacey's classic critique attention; and behavioral components would
(Lacey, 1967) wherein the unitary nature of a account for levels of activity, together with the
physiologically mediated arousal drive, as integration and coordination of motor respond-
advocated by Duffy (1951), was discarded ing. It is suggested that these three systems are
because different autonomic response measures, loosely coupled in a fashion similar to that
behaviors, and situational factors were found to described by OÈhman (1987) for emotion
be dissociable. More recent psychophysiologi- (Figure 1). The failure to observe perfect
cal studies have also failed to demonstrate a coupling by measures either within or between
unitary arousal construct and largely support component systems is essentially similar to the
Lacey's original position (Venables, 1984). de synchrony concept commonly entertained for
Peripheral autonomic measures of arousal, anxiety (Rachman & Hodgson, 1974; Turpin,
therefore, fail to demonstrate high intercorrela- 1991) and frequently encountered elsewhere
tions, and instead display response patterns within psychophysiology (Cacioppo & Tassin-
specifically determined by either individual ary, 1990; OÈhman, 1992).
differences or situational factors. More recent Several implications for therapy emerge if
arousal theories have also discarded the notion arousal is treated according to the systems
of ªarousalº as an unitary construct, but instead identified in Figure 1. First, a comprehensive
have stressed the complexities of stimulusÐ assessment of arousal will involve attempts to
response relationships, different arousal sys- measure all three systems. Indeed, Poppen
tems, motivational systems, and neurophysio- (1988) has written extensively about the multi-
logical or neurochemical substrates (Turpin, modal assessment of arousal and the outcome of
1989). relaxation training. He suggests the use of self-
Given the paucity of evidence to support a report relaxation and symptom scales, specific
unitary arousal construct, it is perhaps para- physiological measures (e.g., electrodermal,
doxical that the construct of arousal continues cardiovascular, electromyogram [EMG], skin
to receive widespread support as an explanatory temperature, and electroencephalogram [EEG]
construct within clinical psychology. This is, changes), and direct behavioral observations
perhaps, best characterized by Gale and (e.g., Behavioral Relaxation Scale). Second, it
Eysenck's (1992) quote from Claridge (1987, becomes evident how overarousal might lead to
p. 134): ªI have often felt that as an explanatory dysfunction and the expression of a variety of
concept in psychology ªarousalº has many of symptoms including subjective distress, hyper-
the qualities of a difficult but persuasive lover, vigiliance and heightened attention, selective
whom reason tells one to abandon yet who appraisal, hyperactivity, disorganized behavior,
continues to satisfy an inescapable need.º The and autonomic and somatic overreactivity. The
question arises, therefore, as to why, particu- presence of such symptoms within a fear
larly within the clinical arena, this irrational situation is consistent with the constructs of
infatuation should continue. One answer is that anxiety or panic. Finally, the three-system
ªarousalº is best viewed as a hypothetical approach suggests a diversity of potential
construct and, as such, it is difficult to define interventions that might moderate the expres-
precisely or to operationalize. However, clinical sion of hyperarousal. The choice between a
psychology deals with many such similar unitary model of arousal reduction and relaxa-
constructs including, for example, ªaffect,º tion, on the one hand, and a multicomponent
SITUATION
Cognitive system
Subjective experience
Verbal report
Attention and vigilance
Proprioception
Appraisal
AROUSAL
Behavioral
Physiological system
system Level of activity and
Cortical activation observed wakefulness
Autonomic responses Organization of activity
Somatic tension Speed
Neurohumoral Clonic movements
and tics
Figure 1 The inferential basis of arousal (based on OÈhman's (1992) construct of emotion). (Ð) Observables
and relationships between observables; (± ± ± ±) inferred constructs.
model with a variety of specific treatment static mechanisms, would lead to dysfunctional
effects, on the other, is discussed later in this patterns of physiological activation character-
section. istic of so-called ªpsychosomatic disorders.º
Indeed, a diversity of theoretical models has been
6.09.2.2 Arousal Dysfunction and Health postulated in which elevated physiological
arousal is included as a component of ªstressº
Despite the difficulties described earlier in and is linked to both predisposition and the
defining and measuring arousal, the construct subsequent expression of a variety of physical
has been used widely in association with etiologic health problems including headache, gastroin-
theories of both physical and mental illness. testinal disorders, hypertension, and asthma
Perhaps the most ubiquitous approach concerns (McEwen & Stellar,1993; Steptoe, 1991; Weiner,
diathesis±stress models of psychophysiological 1977; Wiebe & Williams, 1992). Such models
disorders (Gatchel, 1993). In particular, Stern- either incorporate physiological arousal as a
bach (1966) postulated that situationally specific component of an undifferentiated stress re-
patterns of psychophysiological responding, if sponse (Seyle, 1950), or identify specific path-
not adequately modulated by individual homeo- ways associated with autonomic hyperreactivity
and end-organ dysfunction, as exemplified by arousal and cognitive activation such as pre-
Freedman's hypothesized adrenergic mechan- occupation. We will return in more detail to the
ism implicated in Raynaud's disorder (Freed- three-system analysis of anxiety and arousal
man, 1989). Although psychosomatic disorders when specific therapeutic processes are dis-
are covered elsewhere, they represent a major cussed in later sections of this chapter.
area of study that relies on ªstress±arousalº Specific arousal components can also be
explanations of disease, and hence provide identified for other psychological problems. For
explicit therapeutic rationales for arousal re- example, many sexual disorders are associated
duction interventions (Lehrer, Carr, Sargunaraj, with specific patterns of arousal responding in
& Woolfolk, 1993). Nevertheless, as with the form of nonspecific physiological arousal,
arousal, many have argued that the concept of together with abnormal sexual dysfunction.
ªstressº is too ill-defined and lacks specificity Conditions such as vagismus, erectile dysfunc-
when defining individual mechanisms under- tion, and paraphelia might all be considered as
lying disease or dysfunction (Steptoe, 1980). involving a specific sexual arousal dysfunction.
A similar approach has been taken with Similarly, heightened arousal is an important
regard to mental health, whereby stress is seen component of the expression of aggression and
as a potential threat to mental well-being, and hostility, and may be specifically associated
physiological stress or arousal is seen as a with particular patterns of cardiovascular and
frequent consequence of psychosocial stressors neuroendocrine response. Accordingly, it is
and is manifested in a variety of psychological frequently the focus of treatments aimed at
problems (Turpin & Lader, 1986). Such models anger management. Another disorder that
underpin stress management approaches to might also be considered to include a specific
mental health and the promotion of more arousal component concerns post-traumatic
adaptive life-styles, together with the develop- stress disorder, in which heightened anxiety,
ment of more appropriate coping and adaptive tension, hypervigiliance, and exaggerated star-
responses to challenging stresses and life strain. tle responses are symptomatic features.
Generic stress management approaches (Mei- Finally, the construct of arousal has been used
chenbaum, 1993) are widely used for both as a mediational variable for several other
physical and mental health problems, and are psychological disorders. Although physiological
frequently employed within occupational and arousal may not necessarily be an essential
vocational settings (Reynolds & Shapiro, 1991). component of the expression of the disorder, it is
Within the area of mental health, several hypothesized that an underlying arousal dys-
specific rationales can be identified that link function is instrumental in the expression of the
elevated arousal manifested across physiologi- disorder. For example, the consequences of
cal, cognitive, and behavioral response modes arousal on the habituation and conditioning of
with psychological dysfunction. Several psy- fear responses has been implicated both in
chological disorders are defined with particular theories of phobic fear (Lader & Mathews, 1970)
reference to elevated levels of physiological and in treatment through desensitization
arousal, which are situationally inappropriate (Wolpe, 1982). Habituation is also suggested
and are frequently present in association with as an essential component of anxiety reduction
other aspects of overarousal, such as heightened within in vivo exposure treatments of anxiety
attention and vigilance, somatic tension, and disorders (Foa & Kozak, 1986) and also in the
behavioral hyperactivity. Generally, arousal is response prevention treatment of obsessive-
treated nonspecifically and, for example, can be compulsive disorder (Mills & Salkovskis,
considered as a component of anxiety or even 1988). Elevated physiological arousal has also
sleep dysfunction in the form of insomnia. With been suggested as a substrate underlying
reference to anxiety, the three-system concep- suggested psychomotor disorders such as torti-
tualization of anxiety (Lang, 1968; Kozak & collis (Meares, 1973), tics (Corbett & Turpin,
Miller, 1982; Turpin, 1991) is still the prevalent 1985), and writer's cramp (Cottraux, Juenet, &
conceptual model, particularly when used as the Collet, 1983). More recently, arousal dysfunc-
basis for the evaluation of cognitive behavioral tion has been implicated in relapse for psychosis,
therapies. Physiological, behavioral, and cog- whereby arousal is seen as a mediating pathway
nitive components of anxiety and their mani- in the stress±vulnerability model of schizophre-
festations can easily incorporate the arousal nia (Nuetcherlein & Dawson, 1984; Tarrier and
construct, and may even be reformulated Turpin, 1992). Therapeutic approaches that
whereby arousal is seen as an energetic or drive have sought to modify the stress±vulnerability
component of situational fear or anxiety. relationship, such as coping enhancement stra-
Similarly, insomnia is frequently (Borkovec, tegies (Barrowclough & Tarrier, 1992), fre-
1979; Nicassio & Buchanan, 1981) conceptua- quently include arousal modulation techniques
lized as arising from both elevated physiological and rationales.
In summary, a variety of theoretical models emphasized both cognitive and somatic relaxa-
exist that relate arousal dysfunction to the tion (Davidson & Schwartz, 1976; Heide &
expression of physical and mental health Borkovec, 1983; Lehrer, Woolfolk, Rooney,
problems. These frameworks, therefore, pro- McCann, & Carrington, 1983). The implica-
vide therapeutic rationales for arousal modifi- tions of these approaches are that the arousal
cation methods, assuming that such methods requires assessing across a range of different
exist and can be shown to be efficacious. It is domains, and that different aspects of arousal
worth noting the wide range of problems that reduction methods might target different
have been associated with an arousal dysfunc- sources of arousal.
tion, and this perhaps lends greater credence to The above approach can be contrasted with
Eisenberg et al.'s survey that indicated wide- unitary theories of arousal and relaxation
spread use of ªunconventionalº therapies for a induction, as exemplified by Benson's (1975)
wide range of conditions. In the next section the relaxation response. Many arousal reduction
theoretical rationale underlying the treatment techniques are designed to induce a state of
methods claimed to reduce arousal is reviewed. relaxation, which is conceived of as being
antithetical to either arousal or stress and is
typified as subjective calmness, lowered muscle
6.09.2.3 Theoretical Basis of Arousal tension, and lowered levels of physiological
Modification Methods arousal. Indeed, many authors refer to the
relaxation response in a similar, but opposite,
Various psychological interventions have fashion, to Selye's (1950) stress response.
been suggested to reduce the level of elevated Moreover, several theoretical models have even
arousal (Lehrer & Woolfolk, 1993). The implicated specific physiological mechanisms,
rationale for their use depends on how elevated particularly those related to autonomic balance,
arousal and the mechanisms underlying it are as mediating the relaxation state (Gellhorn,
conceptualized. As seen in the previous section, 1958). The rationale for some arousal reduction
arousal can be defined in a variety of waysÐ methods, therefore, is to lower arousal by the
physiological, behavioral, and cognitiveÐand induction of an opposite and incompatible state
each mode can be measured and assessed of relaxation. This distinction between theories
independently. Moreover, it is likely that of arousal modulation, which rely on specific
elevated arousal is the product of several distinct pathways, as opposed to a unitary model of
processes that may or may not be interrelated relaxation induction is important when evalu-
(see Figure 1). Accordingly, different arousal ating the differential efficacy of these techni-
modification methods might be targeted at ques. If relaxation provides a common pathway,
different components and rely on different it may be that all arousal reduction interven-
mediational processes. tions are equivalent in terms of process, and lead
For example, a cognitive arousal component to identical outcomes, albeit with differing
consisting of hypervigilance and appraisal of degrees of effectiveness in how easily achievable
threat might be ameliorated either by cognitive these outcomes are. Alternatively, if arousal
therapy directed at the beliefs maintaining the reduction or relaxation induction is conceived
negative appraisal or by the reduction and of as a variety of specific components, different
substitution of the prevalence of negative techniques might have differing degrees of
thoughts or worries per se using a cognitive efficacy expressed in different modalities for
distraction technique, perhaps involving med- different individuals and disorders.
itation or imagery. A further reduction in a Indeed, the issue of specificity concerning a
cognitive arousal component might also arise as variety of relaxation methods has been empha-
a consequence of applied relaxation training sized by Lehrer and colleagues (Lehrer, 1996;
directed at reducing physiological arousal, Lehrer, Carr, Sargunaraj, & Woolfolk, 1994;
thereby eliminating a cue associated with Lehrer & Woolfolk, 1993). In contrast to
interoceptive sensations of overarousal. Con- Benson's (1975) unitary relaxation response,
versely, elevated somatic arousal, as induced by, they propose an extension of Davidson and
for example, increased muscle tension and Schwartz's (1976) model, in which relaxation is
accompanying headache, might be reduced viewed as a multicomponent process (of up to 12
specifically by EMG biofeedback and training separate components), and that specific techni-
directed at the muscle group concerned. An ques give rise to specific effects. For example,
emphasis on different arousal components, they suggest that cognitive changes might be
therefore, gives rise to what Poppen (1988) expected from cognitive oriented methods such
describes as multimodal theories of relaxation as meditation; somatic tension changes would
induction. Such theories originated from dua- be brought about by muscle-oriented methods,
listic accounts of arousal reduction, which such as Jacobson's (1938) progressive muscle
relaxation (PMR) or EMG biofeedback; and solely to reductions in muscle tension and
autonomic changes would be brought about by EMG. Jacobson and his followers (see McGui-
either electrodermal/thermal biofeedback or gan, 1993) stressed that proprioceptive feedback
autogenic training. It should also be acknowl- from the musculature directly affects peripheral
edged, however, that specific effects may autonomic activity via the sympathetic and
actually overlie a more generalized induction parasympathetic nervous system. This mechan-
of a relaxation response, and hence these two ism is based on Gellhorn's theories linking
approaches are not necessarily seen as mutually emotional experience to the skeletal muscula-
incompatible. Moreover, it is by no means ture (Gellhorn, 1958; Gellhorn & Kiely, 1972).
conclusive as to how different interventions Accordingly, studies of relaxation training that
should be classified using multicomponent include autonomic measures have generally
models. Autogenic training, for example, can demonstrated additional effects of, for example,
be said to be directed at both autonomic and lowered heart rate and electrodermal levels
cognitive components. Similarly, hypnosis can (Lehrer et al., 1994). Indeed, several studies
also be considered as multimodal. have attempted to assess relaxation effects on
Lehrer and Woolfolk have tried to resolve the the adrenergic system (see Freedman, 1994),
question of unitary vs. multicomponent models and have included measures of peripheral
of relaxation by comparing the effects of muscle sympathetic nerve activity, blood nor-
different relaxation procedures on a range of epinephrine levels (Hjemdahl et al., 1989), and
outcome measures chosen to reflect the com- platelet monoamine oxidase activity (Mathew
ponent processes described by Davidson and et al., 1981). Other studies have also suggested
Schwartz (1976). This has been attempted either effects on the immune system in the form of, for
using a comparative treatment approach re- example, changes in killer cell activity and
viewing the results from different outcome lymphocyte density (Gruber et al., 1993). Other
studies (e.g. Lehrer et al., 1994) or by perform- arousal reduction methods have also been
ing essentially analogue laboratory studies in demonstrated to yield specific physiological
which the effects of these different relaxation effects. For example, breathing regulation
techniques on a battery of psychological and techniques have been shown to lower physio-
physiological measures are contrasted (Lehrer logical arousal and to normalize the EEG
et al., 1983). (Fried, 1993; Lehrer & Woolfolk, 1993).
Generally, these studies are consistent with The physiological effects of more cognitively
the view that the effects of different relaxation mediated procedures such as autogenics and
techniques are mediated by specific changes in meditation have also been reviewed by Lehrer
somatic and cognitive arousal. Reviews, princi- and colleagues (Lehrer et al., 1994; Lehrer &
pally by Lehrer and Woolfolk (Lehrer 1996; Woolfolk, 1993). Although the specific effects
Lehrer et al., 1994; Lehrer & Woolfolk, 1993; model of Davidson and Schwartz would predict
Lehrer et al., 1983), concerning the specific greater cognitive than physiological effects for
effects of relaxation techniques on physiological interventions such as meditation, Lehrer et al.
activity support the contention that muscle conclude that the differential effects of medita-
relaxation training, either in its original form as tion vs. relaxation training are equivocal. With
PMR (Jacobson, 1938) or in its modified form respect to autogenic training, Linden (1990)
as abbreviated progressive relaxation (APR) cites a collection of studies demonstrating
(Bernstein & Carlson, 1993), produces signifi- physiological effects of autogenic training,
cant decreases in muscle tension as measured by which support the relationship between sub-
EMG. Similarly, EMG biofeedback, either jective somatic sensations and physiological
delivered alone or in conjunction with modified change, particularly in relation to changes in
PMR, has been shown to produce significant breathing and peripheral skin temperature.
decreases in target EMG levels. However, Although the above studies generally sub-
whether the effects produced by EMG biofeed- stantiate the fact that the intended effects of
back delivered to a single muscle site can be relaxation on the levels of physiological activity
generalized to other EMG sites is debatable are observed within treatment sessions, findings
(Alexander, 1975). Similarly, the data remain regarding the longer term effects of relaxation
equivocal as to the comparative effectiveness of on physiological functioning are few. Indeed, a
PMR, APR and EMG biofeedback on reducing recent appraisal of the area which has been most
EMG levels (Lehrer et al., 1994; Lehrer & thoroughly examined, that is, stress manage-
Woolfolk, 1993) although, EMG biofeedback is ment and hypertension, reveals that a cautious
probably superior to APR with regard to EMG approach to extrapolating from short-term
reduction (Lehrer et al., 1994). effects to long-term outcomes might be war-
Nevertheless, the therapeutic rationale for ranted. Although relaxation-based stress man-
muscle relaxation training does not restrict itself agement protocols revealed significant falls in
blood pressure within hypertensive subjects mediational role of arousal in triggering specific
(Patel et al., 1985), recent meta-analyses of symptoms. Accordingly, a variety of therapeutic
studies within this area have produced less- techniques targeted at arousal reduction have
promising findings (Jacob, Chesney, William, been devised in order to alleviate the effects of
Ding, & Shapiro, 1991; Johnston, 1994; but see overarousal.
also Linden & Chambers, 1994; Linden, Stossel, A variety of mechanisms have been proposed
& Maurice, 1996). Some of the factors respon- to underlie these techniques, ranging from the
sible for these disparate findings probably unitary induction of a relaxation response
include pre-existing levels of hypertension, through to specific processes responsible for
subject selection and entry to the study, therapeutic change across different arousal
habituation and initial testing effects on blood components. It would appear that the majority
pressure measurement, and failure of blood of relaxation techniques produce some measur-
pressure reductions to generalize to everyday able effects on a variety of cognitive, somatic,
life situations (Jacob et al., 1991). It remains to autonomic, and central measures. However, the
be seen, therefore, whether the long-term effects effects produced by different techniques do not
of relaxation on elevated physiological arousal appear to be equivalent, as might be predicted
can be demonstrated, particularly if the meth- by a unitary theory such as Benson's. Never-
odological rigors adopted within hypertension theless, there would appear to be evidence of
research were to be more generally applied. some more generalized physiological effects of
Most of the evidence reviewed in this section relaxation on autonomic, neurohumoral, and
was derived from short-term treatment or immune system functioning that underlie spe-
laboratory analogue studies, and as such cific treatment-induced changes. Moreover, it
emphasizes process-related changes in relaxa- should be acknowledged that some specific
tion measures. Whether these changes are also predictions of the multicomponent models have
directly related to stable therapeutic outcomes not been supported.
with regard to reduction in symptoms and
increased functioning remains to be demon-
strated. Moreover, this assumes that the 6.09.3 AROUSAL REDUCTION
fundamental process underlying therapeutic METHODS: GENERAL
change is physiological arousal reduction. PROCEDURES AND SPECIFIC
However, this assumption has recently been TECHNIQUES
challenged by Smith (1988, 1989), who has
proposed that the therapeutic changes brought In this section we systematically review
about by relaxation techniques are best ex- clinical interventions derived in order to reduce
plained by cognitive-behavioral formulations, arousal and facilitate positive functioning and
as opposed to changes in physiological func- therapeutic change. Only those techniques that
tioning. Hence changes in attitudes towards are supported by a clear therapeutic rationale
relaxation and stress, together with specific and that have been scientifically evaluated in
changes in personal cognitive schema, underlie terms of their efficacy are included. In addition,
therapeutic improvement, which may or may the review focuses primarily on mental health
not be accompanied by a lowering of physio- problems prevalent in adults. However, where
logical arousal. The issue of specificity of effect appropriate, procedural modifications for child
will be examined in greater detail in the final and elderly populations are noted. Physical
section of this chapter. conditions such as hypertension, headache, or
pain control will not be systematically covered as
6.09.2.4 Summary these are reviewed elsewhere, but will be referred
to if the studies are able to expand on some
In summary, arousal reduction methods are general procedural issues surrounding the im-
based on a variety of different explanatory plementation of these therapeutic techniques.
therapeutic models. Indeed, the construct of The main techniques reviewed are relaxation
arousal has been difficult to define and cannot methods, autogenic training, breathing modifi-
be satisfactorily operationalized. Nevertheless, cation, biofeedback, meditation, and hypnosis.
despite the construct being less frequently However, many of these techniques have been
employed within experimental psychology, its advocated for use in a variety of different clinical
use as an explanatory factor in clinical psychol- problems based on a diverse range of therapeutic
ogy continues to be prevalent. Many physical rationales. Hypnosis, for example, is claimed to
and mental disorders can be considered to be therapeutically beneficial in inducing a
involve an element of arousal dysfunction, relaxation state, accessing ªinaccessible mem-
either resulting directly in the expression of ories and feelings,º and promoting cognitive
symptoms or indirectly as a result of some restructuring. Accordingly, we will restrict
Arousal Reduction Methods 211
ourselves to covering only specific applications presenting problems. Such a formulation

of these techniques where the therapeutic should address the rationale for the adoption
rationale upon which their use is based concerns of a relaxation-based intervention and should
the reduction or modification of arousal. also rule out other more appropriate treatment
Before reviewing each technique in turn, we approaches. The latter might concern the use of
briefly describe and evaluate some general physically based medical treatments or more
procedural factors. Contraindications and psychotherapeutically based interventions. Not
modification of the technique for specific that these treatments are necessarily mutually
problems or client groups will also be reviewed. exclusive; in the case of psychological interven-
The comparative efficacy of different techni- tions in particular, relaxation techniques may
ques and their use for specific conditions are well be used in conjunction with other cognitive
dealt with in the final section of this chapter, and behavioral approaches. A final purpose of
together with a discussion of the therapeutic assessment should be to identify contraindica-
mechanisms that might underlie their efficacy. tions of applying relaxation-based therapies (see
Section 6.09.3.2.1).
In order to formulate the presence of an
6.09.3.1 General Procedural Issues arousal-related health problem that might be
amenable to relaxation, it is important to verify
The limited scope of this chapter prevents a the presence of elevated arousal either directly
detailed account of the clinical protocols used to through physiological measurement or by
deliver these methods. Instead, we aim to deal inference from observation or self-report.
with some general procedural issues common to Indeed, given the multidimensional nature of
most relaxation or arousal reduction techni- the arousal construct (see Figure 1), it is likely
ques, followed by a brief description of the that individual measures will not be inter-
essential features of each technique. Several changeable and that a multicomponent ap-
excellent practical guides and training manuals proach to assessment will be required.
have been published (Howell & Whitehead, Physiological measures of arousal will require
1989; Payne, 1995; Whitehead & Adams, 1991) sophisticated equipment and expertise, which is
and these should be consulted by the novice unlikely to be available in most clinical settings,
practitioner alongside this chapter. but may well be available if biofeedback
techniques are also on offer within the clinic.
Simple assessments of elevated EMG or heart
6.09.3.1.1 Assessment
rate may also be accomplished using inexpen-
The successful application of relaxation sive commercially available monitors. Further
techniques will depend on sound assessment advice and information on psychophysiological
and formulation of the clinical problem, leading assessment procedures are available elsewhere
to an appropriate rationale for their use. (e.g., Cacioppo & Tassinary, 1990; Turpin,
Assessment should focus on identifying the 1989).
clinical problems amenable to relaxation tech- An alternative to direct measurement is the
niques (Lehrer & Woolfolk, 1993; Poppen, use of either therapist observational checklists
1988), together with establishing the presence of or client self-report instruments. The most
elevated physiological arousal, and self-reports widely used observational scale is the behavioral
or inferred observations of tension, anxiety, or relaxation scale (BRS) (Schilling & Poppen,
worry (Crist, Rickard, Prentice-Dunn, & Bar- 1983), which is discussed in great detail in
ker, 1989; Poppen, 1988; Smith, 1989). Poppen's instructional text (Poppen, 1988). A
As discussed in Section 6.09.2.2, specific wide range of self-report scales is available to
health problems said to be associated with assess, for example, anxiety and worry, somatic
elevations in arousal are generally identified as arousal, stress and tension, state of relaxation
anxiety disorders (e.g., generalized anxiety and calmness. The use of these scales has been
disorder, panic disorder, and specific phobias), reviewed by Smith (1989).
psychosomatic complaints (e.g., hypertension,
tension headache, migraine, and asthma),
6.09.3.1.2 Therapeutic rationale
elevated tension or somatic arousal (e.g.,
chronic pain, insomnia, and skeletomuscular Assuming that assessment has revealed a need
disorders), and palliative problems and applica- for relaxation training, and the most appro-
tions (e.g., side effects of chemotherapy). The priate method has been chosen for the indivi-
purpose of assessment, therefore, is to sub- dual, a common feature of most methods is to
stantiate the presence of any of these clinical present a clear therapeutic rationale to the client
indications, and to provide sufficient informa- (Bernstein & Carlson, 1993). This will usually
tion to arrive at an individual formulation of the involve an explanation or reformulation of the
client's problem in terms of anxiety or an individual progression is based on mastering

inability to relax, the provision of basic informa- each stage and the strict adherence to a
tion on stress and anxiety, and an explanation of standardized and, possibly, inflexible protocol.
how relaxation can be induced and its potential The majority of published studies of relaxation
benefits to the client. The latter will usually training relate to individualized, one-to-one
stress the importance of regular practice and therapy as opposed to group delivery methods.
emphasize that the client must take responsi- However, in practice, many practical relaxation
bility for his or her own therapy. It is important training programs are directed at group ap-
that at the beginning of therapy the client has an proaches (Howell & Whitehead, 1989; White-
accurate expectation of the nature of the thera- head & Adams, 1991). Other considerations
peutic intervention and his or her own commit- include the number of sessions, homework
ment to the therapy. The adoption of a clear practice, compliance, and follow-up and booster
therapeutic rationale, therefore, together with sessions. The overall impact of these factors on
agreed therapeutic goals between therapist and treatment efficacy are now reviewed.
client cannot be overstated. At the very least it
provides the therapeutic framework within
6.09.3.1.5 Evaluation of procedural factors
which relaxation techniques can be learnt and
practised. Indeed, some would argue (e.g., Several of the above general procedural
Smith, 1989) that the therapeutic benefits of factors commonly found in most forms of
relaxation are dependent on the client's refram- relaxation training have been investigated in
ing of the clinical problem cognitively, and arise order to determine their influence on therapeu-
as much from changes in cognitive schema and tic outcomes. These have included taped vs. live
appraisal processes as they do from any instruction, the use of homework practice
accompanying changes in physiological arousal. sessions, and brief vs. extended practice, and
they have been the subject of several reviews
(Bernstein & Carlson, 1993; Borkovec & Sides,
6.09.3.1.3 Practical considerations
1979; Blanchard et al., 1991; Hillenberg &
In addition to introducing to the client an Collins, 1982; Lehrer & Woolfolk, 1993).
appropriate rationale, it is also important that Although none of these reviews yield unequi-
the client is provided with instructions concern- vocal conclusions, several consistent recom-
ing environmental considerations for relaxation mendations emerge. First, live instructions,
training. Important requirements are a comfor- whereby the client is able to control the progress
table chair and the adoption of a reclining of training by moving systematically from one
position, avoiding extraneous noises or inter- muscle group to the next, with access to
ruptions, subdued lighting and a comfortable appropriate observation of and feedback from
ambient room temperature, and the wearing of the therapist, appears superior to the sole use of
loose clothing that does not restrict body standard taped instructions. Second, most
movement. These factors apply both to clinic clinical trials have included home practice
sessions and homework practice. Finally, the sessions, perhaps supplemented by taped in-
adoption by the therapist of a smooth, quiet, structions and measures of homework compli-
and almost monotonous voice for the presenta- ance. Some data exist to support the additional
tion of instructions is also an important benefits of prolonged and regular homework
consideration. practice, although some studies (Borkovec et al.,
1987; Nelson & Borkovec, 1989) have failed to
support such an effect. Compliance and over-
6.09.3.1.4 Presentation of the technique
reporting of homework practice sessions might
Different techniques clearly have to be explain some of the inconsistencies in these
delivered to the client by the therapist in many studies (Bernstein & Carlson, 1993). Third, it
different ways. Nevertheless, certain choices would appear that the greater exposure to
regarding the mode of training have to be made. relaxation training, either through extended
For example, what amount of information is clinic sessions or through continued application
provided prior to training (booklets, audio- outside of the clinic, is more likely to be
cassettes, videos, etc.)? The role of the therapist associated with maintenance of therapeutic
in providing within-session modeling of the change. The continued application of brief
techniques for the client, and the opportunity relaxation procedures, as opposed to more
for the client to rehearse techniques before the extended periods of relaxation training, has
therapist and to receive feedback are examples been argued by Lake and Pingel (1988) to be an
of procedural questions that have to be resolved. important determinant of outcome for head-
Similarly, the therapist has to decide between the ache patients. It should be emphasized, how-
use of individual sequences of exercises, whereby ever, that the above recommendations are
largely based on clinical guidelines rather than tension-release cycle, and greater emphasis on
extensive outcome studies. Moreover, specific subjective and cognitive approaches. Many of
procedural recommendations for different tech- these changes were incorporated into a highly
niques or subject groups have yet to be evolved. influential treatment manual produced by
Bernstein and Borkovec (1973). The specific
instructions underlying the technique involve
6.09.3.2 Specific Techniques the client performing a series of tension-release
The purpose of this section is to provide the cycles in a systematic manner across 16 muscle
reader with a brief account of the essential groups, beginning with the hand and forearm,
components of each technique. More detailed moving through the forehead, face and neck,
clinical protocols are available elsewhere down to the abdomen, and finishing with the
(Lehrer & Woolfolk, 1993). As relaxation-based feet. Each tension-release cycle involves the
techniques have been the focus of this chapter so client contracting the specified muscle accord-
far, greater emphasis will be placed in this ing to a cue ªtenseº or ªnow,º holding and
section on detailing the background to other sensing the contraction for 5±7 seconds, and
techniques, such as biofeedback, meditation, relaxing the muscle on the command ªrelax,º
and hypnosis, which have also been commonly followed by a period of 30±40 seconds during
employed as arousal reduction methods. which the client focuses on the sensations of
relaxation. A detailed account of these proce-
dures is provided by Bernstein and Carlson
6.09.3.2.1 Relaxation-based methods (1993). Various modifications have also been
(i) Jacobson progressive muscle relaxation proposed to the standard Abbreviated Progres-
sive Relaxation Training (ABRT) protocol,
The development and application of Jacob- including the establishment of relaxation cues in
son's ideas have been reviewed extensively by the form of cue-controlled relaxation (Grimm,
McGuigan (1993). Jacobson's method was 1980) and attempts to generalize the relaxation
devised in 1938 and seeks to train subjects in response into everyday settings, such as in
the ability to perceive muscle tension accurately, applied relaxation training (Ost, 1987).
to control and hence reduce tension, and to
relax their muscles differentially. The training
involves detailed familiarization with the ma- (iii) Breathing training
jority of muscle groups and an emphasis on A variety of techniques exist to induce
enhancing awareness of muscle tension. Dis- relaxation through the modification of breath-
crimination training is brought about by the ing. Specific instructions to entrain diaphrag-
method of ªdiminishing tensions,º whereby the matic breathing have commonly been used as
client learns to effect and detect the smallest adjuncts to APR (Bacon & Poppen, 1985;
possible muscle contraction in a variety of Poppen, 1988) and have also been the focus of
different muscle groups. Once the skill of cue-controlled relaxation procedures (Grimm,
discrimination in muscle tension has been 1980). For disorders such as panic, whereby
acquired, the client can then bring about sensations arising from hyperventilation have
ªdifferential relaxationº of his or her muscles, been implicated, controlled breathing exercises
which entails only contracting those specific have been used effectively (Clark, Salkovskis, &
muscles that are functionally required for Chalkley, 1985). More specific techniques
action, and relaxing all other muscles unasso- involving respiratory feedback and slowly
ciated with the ongoing physically active group. paced breathing have also been developed
The distinctive feature of Jacobson's approach (Fried, 1993; Montgomery, 1994). Finally,
is its specific emphasis on muscle tension and breathing regulation is also a common compo-
control, and the absence of any cognitive or nent of yoga (Patel, 1993) and other meditation-
suggestive components directed at the induction based techniques (Carrington, 1993), and these
of a subjective feeling of relaxation. are discussed later.
(ii) Abbreviated progressive muscle relaxation (iv) Autogenic training

Jacobson's techniques were adapted, notably Instead of focusing directly on muscle tension
by Wolpe (1958) and Paul (1966), and modified as a means to induce relaxation, autogenic
in the 1960s to form part of the basis for several training (AT) involves a set of exercises targeted
behavioral treatments, including systematic at various physiological end-organs whereby a
desensitization. The major changes were a shift state of relaxation might be induced. These
from actual to subjective tension, an abbre- techniques have been described in detail by
viated and standardized protocol, use of the Linden (1990, 1993) and are based on the work
of Schultz and further developed by Luther. reinforcement within an instrumental or

ªAutogenicsº, as a term, essentially means ªself- operant-conditioning paradigm. Around that
exerciseº or ªself-inductionº therapy and relies time also, interest had been shown (Kamiya,
on a theoretical rationale whereby the client 1969) in the operant conditioning of the alpha
gains psychophysiological self-control of auto- EEG rhythm (as a means of achieving altered
nomic functioning and is able to achieve states of consciousness) and of changes in skin
relaxation. Control is said to be gained by the conductance (Shapiro, Crider, & Tursky, 1964)
client focusing on body sensations in a passive and heart rate (Engel & Hansen, 1966).
manner. This is achieved by the client subvocally However, these studies on humans were criti-
repeating six standard formulas that are cized by Katkin and Murray (1968) for their
designed to induce physiological change: these lack of controls for mediating responses such as
include the ªheaviness formulaº directed at the breathing.
muscles, the ªwarmth formulaº aimed at Despite the many problems encountered in
peripheral blood flow, the ªheart formulaº replicating some of the above animal laboratory
associated with the heart rate, and the ªbreath- work, it proved very influential and a wide range
ing formulaº targeted at a natural breathing of clinical applications have been investigated
rhythm. Like many other relaxation techniques, since then and have focused mainly on two types
AT has been modified and used in combination of problem. First, anxiety and stress disorders,
with other methods, particularly thermal bio- where the aim of biofeedback is to reduce
feedback (Norris & Fahrion, 1993). Indeed, AT general arousal levels; and, second, disorders
techniques and imagery are commonly em- presenting as somatic problems (e.g., pain,
ployed to assist relaxation induction within a tension headaches, and irritable bowel syn-
range of different procedures. However, it drome), which may be triggered or exacerbated
should be emphasized that the classical use of by overarousal and where again the biofeedback
AT also implies a therapeutic rationale whereby is either aimed at general relaxation or is
the techniques facilitate cathartic experiences in targeted more specifically to the affected organ
the form of ªautogenic discharges.º or function in order to achieve self-regulation.
Biofeedback techniques associated with gen-
eralized arousal reduction have included from
the outset alpha rhythm EEG feedback (Bud-
6.09.3.2.2 Biofeedback
zynski & Stoyva, 1973) and other methods such
Biofeedback is the regulation of autonomic as electrodermal (skin conductance) feedback
nervous system functions, such as blood (usually from the hand) and surface EMG
pressure, heart rate, and sweating, by the feedback, for example, from the frontalis
subject continually monitoring that function muscle, or in combination. The latter techniques
and being rewarded (usually simply by the are now more commonly used and may also be
knowledge of his or her success) for changing employed to augment systematic in vitro or in
that activity in a desired direction. Feedback is vivo desensitization by enabling closer monitor-
usually conveyed either auditorily by the pitch ing of the return-to-relaxation phase, and
of a continuous tone or by using a visual display. thereby assisting patients to achieve this (Stoyva
The idea that a person, with training, can & Budzynski, 1993).
selectively influence the activity of a particular Procedurally, treatment by biofeedback be-
autonomic function, notably in the direction of gins with an assessment of the patient's
diminished arousal, has been in existence for a presenting problem and an explanation of the
long time and is traditionally associated with rationale of biofeedback. Initial training ses-
Eastern practices such as meditation and yoga. sions with the therapist enable the patient to
It has been claimed that practitioners of these become more attuned to cognitions and bodily
forms of meditation have the ability to attenuate events that are associated with increase in
their vital functions (e.g. heart rate) to an arousal. This training has been reported to be
extraordinary degree. In contrast, Western productive in establishing anxiety-evoking cog-
scientific interest in autonomic control has been nitions in the case of generalized anxiety
a recent development and was stimulated by the (Budzynski & Stoyva, 1973). This stage is
work of Miller and his colleagues on the operant followed by daily practice at home (multiple
conditioning of autonomic responses in ani- short sessions) until mastery of the target
mals, particularly the curarized rat. This response has been achieved and the patient
research was significant from a theoretical can be weaned off the biofeedback device.
standpoint because the findings suggested that Again, it should be noted that biofeedback is
autonomic and visceral responses, hitherto held often combined in treatment with other self-
only to be amenable to alteration by classical relaxation methods, such as autogenic training
conditioning, could be modified by positive or progressive relaxation (Lehrer et al., 1993).
6.09.3.2.3 Meditation 6.09.3.2.4 Hypnosis
Shapiro (1982) defines meditation as referring The origins of hypnosis may be traced back to
to ªa family of techniques which have in the ideas and practices of the Austrian physician
common a conscious attempt to focus attention Franz Anton Mesmer (1734±1815). However,
in a non-analytical way and an attempt not to so great has been the transformation since that
dwell on discursive, ruminating thoughtº time that mesmerism, on the one hand, and
(p. 268). However, he points out that this modern hypnosis, on the other, bear little
definition covers a wide variety of methods of resemblance to one another. Hypnosis as it is
meditation. Moreover, the methods may involve now practised may be operationally defined as
either a state of mental relaxation, or excitement
and arousal; either physical restfulness or, as in an interaction between two people (or one person
the case of the whirling dervish or tai chi, and a group) in which one of them, the hypnotist,
physical activity; and different prescriptions as by means of verbal communication, encourages
regards the distribution of attention (focus on the other, the subject or subjects, to disattend to
awareness generally, focus on a specific thought, their immediate realities and concerns and to focus
their awareness on inner experiences such as
or a shifting form one to the other). In general,
thoughts, feelings and imagery. The hypnotist
however, it is not the contents of awareness that further attempts to create changes in the way
are significant but the process of attending to the subjects are feeling, thinking and behaving by
objects of one's awareness. directing them to imagine various events or
Such a definition of meditation presupposes situations which, were they to occur in reality,
no adherence to any cultic philosophy or beliefs, would evoke the intended changes in the subjects.
a point made by Carrington (1993) in her (Heap, 1995, p. 649)
overview, citing transcendental meditation as
the most widely known and extensively studied The state of inner focus (which is almost
of the Western methods. Carrington goes on to invariably, though not always, associated with
distinguish two methods that have been used in feelings of calmness and physical relaxation) is
clinical settings, namely clinically standardized what nowadays most practitioners appear to
meditation and the respiratory one method. In mean by a ªtrance.º As such it is continuous
the former, the meditator selects a mantra with everyday experiences that are popularly
(usually not a real word) which he or she initially given that label (e.g., absorption in a day-
repeats aloud with the instructor in the training dream). It is generally achieved by the hypno-
phase. Later, the mantra becomes the focus for tist's use of suggestions and imagery, which
silent meditation, twice-daily for 20 minutes denote feelings of calmness, heaviness, tired-
being recommended, although many meditators ness, sleepiness, and so on, a procedure known
reduce the frequency of sessions to one per day as ªhypnotic induction.º Whichever method is
or less after training (Carrington, 1993). Train- used, it may be learned by the patient and
ing is facilitated by written instructions and a practised regularly at home, either by himself or
cassette tape. The respiratory one method herself or with the aid of a recorded tape. At its
(Benson, 1975) requires the meditator to repeat simplest then, ªself-hypnosisº resembles medi-
silently the mantra (which may simply be the tation and other self-directed relaxation proce-
number one), pacing this with the outward dures such as progressive muscular relaxation
breath. It is thus more structured, and is and autogenic relaxation, and the general aims
presumed to be more ªeffortfulº than the above are similar (Sanders, 1993).
method (Carrington, 1993). In the ªheterohypnoticº context, having
Meditation is recommended as an activity for performed an induction procedure, the hypno-
everyday living, one which reduces the stress of tist proceeds to give suggestions to the patient
daily life, encourages a calmer outlook, pro- that are intended to elicit the desired therapeutic
motes greater self-awareness and inner content- changes. It is useful, however, to bear in mind
ment, and so on. However, it has also been used that rather than a therapy in itself, hypnosis is
clinically in the case of anxiety (Kabat-Zinn best regarded as an adjunct to therapy (Gibson
et al., 1992; Kirsch & Henry, 1979; Thomas & & Heap, 1991), and the range of problems to
Abbas, 1978), insomnia (Woolfolk, Carr-Kaf- which it is applied almost matches that seen in
feshan, & McNulty, 1976), hypertension (Surut, any mental health context. Thus it may be used
Shapiro & Good, 1978), psoriasis (Gaston, to augment a cognitive-behavioral approach to,
1988±1989), asthma (Honsberger & Wilson, say, anxiety management by the use of sugges-
1973), and alcohol and drug abuse (Benson & tions of calmness and symptom control in
Wallace, 1971; Parker, Gilbert, & Thoreson, mentally rehearsed, anxiety-provoking situa-
1978; Taub, Steiner, Weingarten, & Walton, tions, and posthypnotic suggestions (i.e. sugges-
1994). tions to take effect after the hypnotic session) of
the immediate and effective use of self-control instigated, directed and terminated at his or her
techniques in such situations. These procedures, own initiative. Consequently, patients require a
which may be targeted at any of the autonomic, certain level of autonomy and ability to manage
cognitive, or behavioral levels, may be aug- their own daily activities, and perhaps a more
mented by the use of cues or ªanchors.º For ªinternalº locus of control (see the review by
example, a positive feeling may be coupled with Lehrer & Woolfolk, 1993).
a simple gesture such as the clenching of a fist Adherence to a prescribed program of self-
(Stein, 1963); this technique may be rehearsed directed relaxation has been noted to be a
repeatedly in imagination, and the posthypnotic problem by a number of authors (Bernstein &
suggestion be given that this feeling may be re- Carlson, 1993; Carrington 1977; Linden, 1993)
evoked by the same action as and when and some studies have indicated overreporting
required. of home-based practice by patients (Hoelscher,
Another very common routine is that of ªego Lichtenstein, & Rosenthal, 1986). A problem
strengtheningº; this consists of suggestions, that is more serious than simple lack of
usually delivered towards the end of a session discipline on the patient's part (or inadequate
of hypnosis, which are intended to promote self- instruction or direction on the therapist's part)
confidence and more positive self-esteem. Use is may be that training in self-regulation does not
often made in this procedure of symbolic and satisfactorily address the patient's problems.
metaphorical imagery and guided fantasy There may also be issues relating to secondary
(Stanton, 1990, 1991). gain or marital and family relationships, or
Hypnotic procedures are often used as an unacknowledged or undisclosed areas of diffi-
adjunct to dynamic psychotherapy, notably by culty and anxiety that need to be the focus of a
the use of what are termed ªexploratoryº and more extensive cognitive behavioral or psycho-
ªuncoveringº techniques. These include age dynamic intervention.
regression and various guided imagery techni- Another characteristic of potential relevance
ques (Gibson & Heap, 1991; Karle, 1988), and to patient selection is absorption, the tendency
are generally based on the notion that uncon- of an individual to become deeply immersed in
scious processes lie at the root of the patient's the object of his or her attention (e.g., a book,
presenting problem. Nevertheless, these techni- some music, or a daydream). This quality may
ques may be put to good use by the eclectically be measured using a standardized questionnaire
minded cognitive or behavior therapist (Gibson (Tellegen & Atkinson, 1974). There is a modest
& Heap, 1991; Heap, 1991). relationship between absorption and measured
One difference between hypnosis and other hypnotic susceptibility (Council, Kirsch, &
methods of arousal control is that the capacity Hafner, 1986), and there is some evidence of a
to respond to hypnotic suggestions varies tendency for good meditators to be high on
(around a central tendency) among the popula- absorption (Davidson & Goleman, 1977).
tion, and is a relatively stable trait (Hilgard, Hypnotic susceptibility is itself related to
1991). Standard scales exist for measuring outcome in several of these self-regulation
hypnotic susceptibility (or, as some would methods, although only modestly so, and not
prefer, suggestibility) and these have good at all in the case of biofeedback (Lehrer &
psychometric properties (for a useful overview Woolfolk, 1993; Sigman & Phillips, 1985).
see Fellows, 1988). However, because so many Whereas, as was stated earlier, practitioners
factors contribute to the outcome of therapy may make use of self-regulation procedures in
and because hypnosis tends to be used in an combination, biofeedback and hypnosis do not
adjunctive manner, the relationship of hypnotic appear to complement one another in this way,
susceptibility to therapeutic outcome is highly and the net effect may be less positive than either
variable and tends to be of modest proportions technique used alone (Edmonds, 1979; Sigman,
(Spinhoven, 1987; Wadden & Anderton, 1982). 1988). Dumas (1980) has suggested that differ-
ent attentional processes may be involved in
these two methods.
6.09.3.3 Indications, Side Effects, and There is a case for favoring high susceptibility
Contraindications subjects as candidates for hypnotic self-regula-
tion in, for example, an anxiety-management
6.09.3.3.1 Client selection
training program that relies heavily on sugges-
The self-regulation methods presented here tions of automatic responding (Spinhoven,
have the advantage that their immediate aim is 1987). There is also a case for offering hypnosis,
to create pleasant experiences purely from and even simply explicitly calling the procedures
something the patient does for him- or herself, ªhypnosis,º when it is the treatment requested by
and ultimately, at any time, control of treatment the patient, and not doing so when the patient
is in the hands of the patient, and may be has a negative attitude to hypnosis (Kirsch,
1996). Perhaps equivalent recommendations ªcalmº and ªrelax.º In the case of fear of loss of
may be made in the case of the other methods. control, the use of a more individualized
approach, self-paced by the client, should be
considered. If problems persist, the therapist
6.09.3.3.2 Side effects and adverse reactions
should consider adopting a different technique,
Notwithstanding the relatively benign nature preferably based on some formulation as to why
of the procedures under discussion, adverse the side effects are being experienced with the
effects have been noted in the literature, and current relaxation method employed.
precautions and contraindications have been Finally, it should be recognized that the
detailed by various authors (e.g. Shapiro, 1982, possible presence of unreported side effects
for meditation; Bernstein & Borkovec, 1973, for might account for treatment noncompliance
progressive relaxation; Linden, 1993, for auto- and rates of uptake and dropout within therapy.
genic training; and Crawford, Hilgard, & As will be discussed in greater detail in Section
Macdonald, 1982, for hypnosis). Reported 6.09.4.2, relaxation-based treatments have
effects, which are generally transient, include compared favorably with more recently evolved
unwelcome and intrusive imagery, anxiety, cognitive-behavioral techniques, sometimes
panic, dizziness, confusion, restlessness, and rather unexpectedly since they have frequently
headache. For example, Edinger and Jacobsen been included in therapy outcome studies as a
(1982) surveyed 116 clinicians who reported on control condition. However, there are strong
the effects of relaxation training on 17 542 indications that they may be less acceptable to
clients. The following prevalence of problems clients, resulting in lower uptake and higher
was reported: intrusive thoughts (15%), fear of dropout rates in therapy. Such effects may be
losing control (9%), disturbed sensory experi- due to a variety of factors, such as treatment
ences (4%), muscle cramps and spasms (4%), credibility and client expectations; however,
inappropriate sexual arousal (2%), and dis- negative side effects might also account for
sociation (0.4%). Other problems less fre- possible reduced acceptability.
quently reported included laughing, coughing,
and falling asleep.
6.09.3.3.3 Contraindications and procedural
Indeed, the presence of such side effects has
modifications
led to the awareness of a particular problematic
response known as ªrelaxation-induced anxiety There is a limited literature regarding the
(or panic),º which appears to represent a suitability of arousal reduction techniques for
cumulative build-up of arousal during the specific clinical problems or client groups.
relaxation procedure itself. Explanations have Where contraindications have been recom-
included fear of losing control, fear of the mended they tend to have been founded on
sensations of relaxation itself, ªinteroceptive clinical observation rather than on outcome
conditioningº and brief bursts of hyperventila- data, and it is often uncertain whether specific
tion (Adler, Craske, & Barlow, 1987; Bernstein warnings of adverse effects can be generalized
& Borkovec, 1973; Borkovec, 1987; Braith, across all methods. A brief overview of these
McCullough, & Bush, 1988; Ley, 1980). issues is provided here, together with some
These effects do not in themselves contra- possible procedural modifications for specific
indicate the use of relaxation procedures in the client groups that might result in making these
individual so affected; exploration of the techniques more appropriate.
reasons for their occurrence, and adjustments The presence of clinical depression is an
to the procedure may be required. For example, important factor to consider. Shapiro (1982),
within the pretreatment rationale it may be for example, suggests that meditation may not
useful to acknowledge the existence of side be appropriate for chronically depressed in-
effects, while emphasizing that their occurrence dividuals, for whom a low level of arousal is
is usually infrequent. When side effects do more characteristic. Neither, the same author
occur, this is confirmation of the prior informa- argues, is it pertinent to the needs of the socially
tion provided and less likely to be interpreted in withdrawn individual. Depression has also
a catastrophic manner. The client should be traditionally been said to contraindicate hyp-
assured that side effects are probably of a nosis (Burrows, 1980), one argument being that
transitory nature and that, from a positive and it can have mood-elevating properties that may
constructive perspective, they indicate that the provide the suicidally depressed patient with the
training is clearly having some effect. In this way impetus to take his or her own life. There is not,
the client is also engaged with the treatment. however, a great deal of evidence for this, and in
Adaptive strategies may include focusing on recent years hypnosis has been used to augment
breathing in order to reduce the likelihood of cognitive-behavioral therapy of depression
hyperventilation, and the use of mantras such as (Alladin & Heap, 1991). Lehrer et al. (1993)
have also reviewed whether stress management There are some other conditions the presence
techniques in general, but particularly those of which warrants special consideration by the
involving relaxation training, should be directed therapist. For example, Carrington (1993)
at depression, since received clinical wisdom advises careful monitoring of patients' medica-
would counsel against such an approach. Again, tion requirements (antihypertensive and anxio-
they report that stress management is associated lytic drugs), as these may alter during treatment.
with improvements in depression, particularly Stoyva and Budzynski (1993) give a similar
when it is combined with other therapeutic warning for patients with insulin-dependent
approaches. Nevertheless, they only cautiously diabetes. Clearly, patients should not deny
suggest the possible inclusion of stress manage- themselves their essential medication in the
ment in programs for the treatment of depres- belief that otherwise they are failing in their self-
sion in view of the problems of motivating regulation procedure (Gibson & Heap, 1991).
clients to comply with an active homework- In addition to specific clinical problems that
based therapeutic intervention, and the need to might mitigate against the use of arousal
ensure that the most effective treatments are reduction techniques, the applicability of these
employed in the case of potentially suicidal techniques in general to certain client groups has
clients. We may conclude that self-regulation been questioned. Essentially, there are two
may be used with the clinically depressed patient major considerations: do clients possess suffi-
with due care, and as one component of a cient cognitive functions to benefit from such an
broader therapeutic program. approach, and are there any physical barriers
One adverse consequence of the methods in that might prevent the implementation of
question seems to be, as in the case of depression, relaxation or other related exercises? Client
the amplification of an existing negative internal groups that might be considered unresponsive
state. Individuals who lack well-developed to a stress reduction approach because of
reality-testing processes, such as psychotic and cognitive or developmental limitations might
borderline patients, and indeed who may halluci- include children, people with a learning dis-
nate, may be unsuitable candidates for self- ability, or individuals with acquired brain
regulation methods, at least without close damage. Poppen (1988) specifically reviews
supervision (Carrington, 1977; Gibson & Heap, the application of behavioral relaxation training
1991), and there is some evidence that prolonged with these populations, and provides examples
meditation may precipitate psychotic episodes in of successful interventions. Similarly, Lehrer
some highly vulnerable individuals (Lazarus, et al. (1993) have reviewed applications of stress
1976). Similarly, Adler and Morrisey-Adler management techniques specifically for chil-
(1983) have reported the possibility of increased dren, and report positive findings in relation to
hallucinations with biofeedback training. hyperactivity and academically related anxiety
Nevertheless, Lehrer et al. (1993) have reviewed problems.
several studies purporting to report beneficial Physical restrictions such as arthritis or
effects of stress management within psychosis. neuromuscular dysfunction can give rise to
Given the contemporary interest in psychologi- serious obstacles to using muscle relaxation
cal management techniques for psychotic symp- based methods with either brain-injured or
toms, it is perhaps time to reassess the elderly populations. Two different approaches
application of these techniques to schizophrenia. might be used to overcome this problem. First, a
Moreover, many of these recent approaches to variant of PMR has been designed that is based
the psychological management of psychotic not on muscle contraction but on muscle
symptoms are based on the stress±vulnerability stretch. It is argued by Kay and Carlson
model (Clements & Turpin, 1992; Tarrier & (1992) that this approach might be more
Turpin, 1992), which identifies increases in acceptable to older adults. Second, it could be
arousal as an underlying mechanism in the argued that more cognitively focused interven-
production of psychotic states. Further support tions might be of greater benefit to older adults
for such an approach may also be derived from who experience either restricted movement or
studies of clients' own self-control strategies for arthritic pain. For example, Scogin, Richard,
psychotic phenomena, which commonly include Keith, Wilson, and McElreath (1992) have
arousal reduction methods. Indeed, these have demonstrated that imagination-based relaxa-
been capitalized on by Tarrier and Barrow- tion procedures were as effective as APR for an
clough's therapeutic approach known as self- elderly population. Deberry, Davies, and Re-
control enhancement therapy. It remains to be inhard (1989) have also reported that a
seen, however, if these techniques are useful in meditation based relaxation approach was more
both relieving psychotic symptoms as well as effective than a purely cognitive approach in
reducing excessive levels of anxiety in these dealing with emotional problems in an elderly
clients. group of clients.
Comparative Outcomes and Therapeutic Mechanisms 219
6.09.4 COMPARATIVE OUTCOMES AND associated with reductions in behavioral avoid-

THERAPEUTIC MECHANISMS ance and distress. However, he suggested that
the use of only relaxation is probably inferior to
In this final section we briefly address the exposure treatments. Using a meta-analysis
issue of comparative outcomes for a variety of approach, Eppley, Abrams, and Shear (1989)
adult mental health problems, focusing parti- compared the effects of different relaxation
cularly on anxiety disorders. In doing so, we techniques on measures of trait anxiety. They
draw attention to relationships between various concluded that transcendental meditation was
techniques of arousal reduction and differential superior to other techniques, and suggested that
therapeutic responses across a range of outcome this might be related to the emphasis given to
measures. We also speculate about possible ªeffortless relaxation,º the concentration of
therapeutic processes that might underlie these training sessions within the first few weeks, and
different relationships. the regularity and duration of practice. Ex-
pectancies and demand characteristics were said
6.09.4.1 Overview of Outcomes not to influence effect size. However, these
conclusions should be treated cautiously, espe-
In Section 6.09.2.3 we discussed the evidence cially when generalizing to adult mental health
supporting the notion of treatment specificity populations, since studies involving psychiatric
across a range of arousal reduction methods. patients were excluded from these analyses,
However, the majority of these studies focused mainly because of the lack of application of
on within-session changes and relied on either transcendental meditation to this subject po-
experimental or analog designs as opposed to pulation. Similar narrative reviews have been
clinical outcome studies employing patient published by Lehrer et al. (1994) and provide
samples. Moreover, the question that was useful overviews of the comparative efficacy of
addressed concerned the effectiveness of indivi- relaxation techniques in relation to, for exam-
dual techniques in modifying various measures ple, psychosomatic disorders, insomnia, anger
of arousal or stress. For example, if EMG management, and substance abuse.
biofeedback is compared to PMR, which Instead of focusing solely on arousal reduc-
method gives rise to the greatest change in tion techniques, more recent outcome studies
arousal as measured by muscle tension, auto- have tended to address the comparative efficacy
nomic activity, and self-reported calmness? of a range of cognitive-behavioral interventions
Although such studies lend credence to the for specific disorders. This reflects the growth of
validity of the proposed therapeutic mechanisms psychotherapy outcome research for anxiety
said to underlie these techniques, and although disorders and the continued inclusion of
they support, to some degree, the treatment relaxation-based therapy components within
specificity hypothesis (see Lehrer & Woolfolk, these studies. However, it should be recognized
1984), they do not address the question of that the rationale for the inclusion of arousal
clinical efficacy for individual disorders. To reduction methods has differed across indivi-
achieve this, it is essential that studies include dual studies. Some researchers, probably influ-
clinical samples that fulfil specified diagnostic enced by Mark's (1976) negative critique of the
criteria, that therapeutic change is assessed with importance of relaxation in exposure treatment
respect to specific measures of psychological (but also see Wolpe, 1989), have included
distress and functioning and not just arousal relaxation based techniques as control condi-
dysfunction, that suitable designs are employed tions in order to assess the additional beneficial
to assess the contribution of nonspecific treat- effects of behavioral or cognitive treatment
ment effects, and that long-term follow-up modalities. Other researchers (Borkovec &
assessments are also included. Costello, 1993; Ost, 1987) have employed
Many reviews exist that focus on clinically relaxation protocols as treatments in their
relevant studies as described above. Some of own right.
these were discussed in Section 6.09.3.1 in We will focus mainly on panic disorder,
relation to the effectiveness of different proce- agoraphobia, and generalized anxiety disorder.
dural components of relaxation techniques, Before reviewing work in these areas, however,
such as homework compliance and taped the issue of whether relaxation training leads to
instructions. Others have compared the general any additional beneficial effects on fear reduc-
effectiveness of arousal reduction techniques in tion in simple phobias when compared to
modifying psychological distress in patient exposure alone needs to be addressed.
samples. An early review by Glaister (1982) McGlynn, Moore, Rose, and Lazarte (1995),
concluded that relaxation training leads to in a study of clinically anxious snake-phobic
decreases in autonomic arousal both within students, reported that group abbreviated PMR
and across sessions, and that these changes were training, in association with in vivo exposure, led
to less behavioral avoidance, reduced auto- beliefs predicted therapy outcomes, and this was
nomic activity, and lower levels of subjective equally true for both treatments. We discuss this
distress compared to exposure alone. It would finding further in the final section of this
appear, therefore, that Marks had prematurely chapter.
dismissed the potency of relaxation techniques Given the relative success of cognitive-
in fear reduction. behavioral treatments for agoraphobia and
The relationship between relaxation and panic, psychosocial interventions have also
exposure has been a focus of outcome research been advocated for generalized anxiety dis-
in both agoraphobia and panic disorder. order. Barlow, Rapee, and Brown (1992)
Michelson, Mavissakalian, and Marchione compared relaxation, cognitive therapy, and
(1988) compared paradoxical intention, their combination to a waiting-list control
therapist-assisted exposure, and relaxation on group. All three treatments were superior to
a range of outcome measures. Overall, the three the control condition on measures of worry and
treatments were equally efficacious and demon- anxiolytic medication usage, and these gains
strated significant improvements post-treat- were maintained at two-year follow-up. How-
ment and at a three-month follow-up. It ever, no differences emerged between treatment
should be noted that all groups underwent a groups and following treatment most patients
general induction program that stressed the were left with significant residual symptoms.
importance of self-directed exposure. In a later Moreover, the dropout rate was high among the
analysis, Michelson et al. (1990) examined active treatment groups. Similar results were
differences in the three treatment modalities obtained by Borkovec and Costello (1993), and
on psychophysiological processes and out- indicated that cognitive-behavioral therapy
comes. Relaxation produced greater reductions (CBT) and applied relaxation were superior to
in physiological arousal than did graded a nondirective therapy control group. Some
exposure, whereas paradoxical intention had between-treatment differences did, however,
no effect. However, despite earlier research suggest themselves. Applied relaxation ap-
indicating that patterns of synchrony± peared to favor greater reductions in daily
desynchrony might predict differential out- anxiety ratings and diary measures, whereas
comes for these treatments (Turpin, 1990), no CBT seemed more effective for worry and
reliable relationships were obtained. depression. At a 12-month follow-up, CBT
In a review of the treatment of panic disorder, showed greater maintenance of therapeutic gain
Craske (1991) reports the superiority of a (58% vs. 38% high end-state functioning) than
cognitive exposure group to relaxation alone applied relaxation. Following a review of
on decreasing panic-attack frequency. How- existing outcome studies for generalized anxiety
ever, relaxation was more effective at reducing disorder, Borkovec and Whisman (1996) come
general somatic symptoms and daily anxiety to similar conclusions, and recommend a
ratings during the course of therapy. Unfortu- combination package of CBT and relaxation
nately, at 6- and 24-month follow-up, the training, targeting both somatic and cognitive
relaxation group showed deterioration, while features of anxiety.
the exposure and combined exposure and Finally, some mention should be made of
relaxation groups demonstrated maintenance outcome studies that have used nonrelaxation-
of therapeutic gains. Moreover, the relaxation based arousal reduction methods. Rice, Blan-
alone group experienced higher attrition rates chard, and Purcell (1993) compared different
from therapy. In contrast, more positive results biofeedback treatments (EMG and alpha EEG)
have been obtained by Ost and colleagues (Ost with two control treatment conditions (EEG
& Westling, 1995; Ost, Westling, & Hellstrom, and pseudomeditation), and a waiting-list
1993) using applied relaxation training (Ost, group. All four treatment groups, including
1987). The first of these studies suggested that the control treatment conditions groups,
relaxation, exposure, and cognitive therapy showed some improvement compared to the
were equally efficacious in the treatment of waiting-list control group. However, small
agoraphobia, if used in combination with self- sample sizes and a restricted number of
exposure instructions. The more recent study treatment sessions limit the conclusions that
attempted to replicate Clark et al.'s (1994) can be drawn from this study. The utility of
findings that cognitive-behavior therapy was ªmindfulness meditationº used in conjunction
superior to applied relaxation. Instead, Ost and with a stress-management program for patients
Westling (1995) again reported generally diagnosed with a variety of anxiety disorders
equivalent outcomes for the two therapies. (panic, agoraphobia, generalized anxiety dis-
However, in agreement with the cognitive model order, etc.) is reported by Kabat-Zinn et al.
of panic proposed by Clark (1986), the present (1992). In discussing the success of their
study demonstrated that measures of cognitive program, the authors reflect on the potential
Comparative Outcomes and Therapeutic Mechanisms 221
benefits of ªmindfulness meditation,º and draw would suggest that a common pathway invol-
attention to the ability of clients to experience ving cognitive beliefs mediated therapeutic
their thoughts directly as ªjust thoughtsº in a change for both these interventions, as predicted
nonreactive way, which leads to a decatastro- by Clark's (1986) cognitive model of panic.
phizing of the situation. It may be that this is a The question arises, therefore, of how the
similar process identified by Borkovec and specific effects model can accommodate find-
Roemer (1994) as ªletting goº within applied ings such as the above. The answer is probably
relaxation, or the ªeffortless relaxationº dis- to be found in more recent models of ther-
cussed by Eppley et al. (1989) in relation to apeutic change, which involve concepts such as
transcendental meditation. emotional processing (Borkovec, 1994; Foa &
Kozak, 1986; Rachman, 1980) and give rise to
6.09.4.2 Therapeutic Mechanisms more dynamic explanations of change that
involve an interplay between a variety of more
We wish to conclude this chapter by addres- discrete psychological processes such as phy-
sing the question of whether different thera- siological arousal, preattentive biases, affective
peutic pathways can be identified, albeit rather response, associative networks, imagery, cog-
speculatively, that share some commonality nitive avoidance, worry, and extinction. The
both within different arousal reduction methods exact nature of the interplay depends on the
and across cognitive-behavioral approaches in therapeutic technique considered, together with
general. Starting with Lehrer and Woolfolk's the nature of the clinical problem. Within this
treatment specificity position, which was de- context, we would argue that arousal reduction
rived from Davidson and Schwartz's specific techniques might yield more subtle therapeutic
effects model, we can classify a range of arousal gains through a variety of possible pathways.
reduction methods according to their putative To illustrate this, we provide here some
therapeutic effects. Hence, progressive relaxa- speculative examples of how relaxation techni-
tion and biofeedback are essentially considered ques might yield the suitable conditions that
as somatic or physiologically oriented techni- bring about enhanced emotional processing and
ques, whereas meditation and cognitive stress therapeutic change.
management approaches are regarded as cog- Before we can discuss the link between
nitive techniques. The logic of this model, arousal reduction and emotional processing,
therefore, is to match the therapeutic method to we need to outline what is meant by the latter.
the presenting problem. Hence, it is suggested According to Foa and Kozak (1986), emotional
that somatically based treatments might benefit processing occurs when maladaptive fear struc-
problems characterized by excessive autonomic tures are accessed in memory repeatedly, and
and muscular arousal. Implicit in this approach fully processed, resulting in affective and
is a rather simplistic opponent process model of physiological responding. In addition, this
therapy, whereby presenting problems are processing results in changes to the structure
ameliorated by the addition of an opposing of the associative network responsible for
therapeutic component. However, recent out- representing the meaning of the fear object.
come studies appear not to support such a With repeated exposure, together with full
simple relationship. processing, extinction of the fear cues and their
If panic disorder is considered, the specific associations is brought about. Factors that are
effects model would specify that relaxation said to influence this process are level of arousal,
ought to target more somatic change, whereas early detection of threat cues, cognitive engage-
cognitive therapy should give rise to greater ment and avoidance, depth of affective proces-
attitudinal shifts, etc. Although there has been sing and emotional responding, worry, and
some support for this suggestion (Craske, 1991), distraction, together with overarching changes
in as much as relaxation was reported to bring in attitude associated with mastery, coping,
about greater reduction in daily symptomatic safety, and other metacognitive structures.
ratings whereas cognitive approaches brought We would argue, therefore, that in the case of
about a greater decrease in overall panic emotional disorder, arousal reduction techni-
frequency, the majority of outcome studies ques yield a variety of therapeutic effects
have yielded more equivocal results. For through their ability to enhance emotional
example, Ost and Westling have reported that processing. We further speculate that these
both applied relaxation and cognitive therapy techniques provide several quite discrete me-
yield roughly equivalent positive outcomes for chanisms through which such facilitation might
agoraphobia. However, the major predictor of be achieved. These influences of arousal reduc-
overall therapeutic outcome across both treat- tion techniques on emotional processing and
ments were measures of cognitive beliefs (Ost & consequent therapeutic change are outlined in
Westling, 1995; Westling & Ost, 1995). This Table 1. First, we suggest that the consequences
of gaining competence in any arousal reduction/ suggested that the depth of processing might be
relaxation induction technique can be consid- enhanced by relaxation. An associated observa-
ered with respect to three general areas of tion from Borkovec's research is the observation
functioning. These are direct changes in phy- that generalized anxiety disorder and worry are
siological activity, changes in ongoing attention associated with autonomic inflexibility, and that
and other associative processes (e.g., access to therapeutic improvement is associated with an
associative networks), and longer term cogni- increase in parasympathetic activity. It is too
tive, attitudinal, and behavioral changes. early, however, to speculate about the direction
Clearly, many relaxation techniques are said of this relationship. Finally, the association with
to result in altered physiological functioning, decreased arousal and extinction of fear has
such as greater cortical deactivation, increased been fundamental to many accounts of desen-
parasympathetic activity, decreased sympa- sitization (Lader & Mathews, 1970) and is still
thetic activity, and lowered muscle tension. relevant to more contemporary models of fear
These changes may well be intrinsically ther- conditioning (Davey & Matchett, 1996) and
apeutic, since they represent direct therapeutic other therapeutic procedures such as eye-move-
targets in their own right (i.e., reduced muscle ment desensitization and post-traumatic stress
tension, lowered blood pressure, etc.) and may disorder (MacCulloch & Feldman, 1996; Sha-
also be associated with longer term physiolo- piro, 1995).
gical benefits with respect to neuroendocrine Changes in physiological activity may also be
and immune functioning. We would argue, represented indirectly as altered interoreceptive
moreover, that these changes in physiological feedback within a third general area involving
arousal may also lead to therapeutic changes cognitive change. Since it has been argued
within a second area of functioning known as (Clark, 1986) that nonspecific bodily sensations
ªemotional processing.º Several authors (Bor- might provide a cue for catastrophic attribu-
kovec, Lyonfields, Wiser, & Deihl, 1993; Foa & tions within panic disorder, any modification of
Kozak, 1986; Shapiro, 1995; Turpin, 1991) have these sensations, either due to relaxation or even
medication, might have beneficial effects. This
approach has been specifically developed
further by Borkovec and Roemer (1994),
Table 1 Targets for potential therapeutic change
arising from the implementation of arousal reduction whereby applied relaxation is combined with
techniques. early cue detection and self-control desensitiza-
tion. It would be expected that decreases in
Physiological subjective bodily sensations and tension would
also be accompanied by increases in subjective
Alteration of autonomic and endocrine functioning:
Central deactivation
calmness, etc. Finally, a word of caution is
Increased parasympathetic activity warranted, since it has also been argued that a
Decreased sympathetic activity potential therapeutic strategy is to train clients
Reduced muscle tension to disattend to interoreceptive sensations
Altered breathing (Wells, 1990). Somatically based relaxation
Endocrine changes techniques might contradict such an approach,
Immune function changes and this may be apposite when clients occa-
sionally experience relaxation-induced panic.
Emotional processing The extent to which interoceptive feedback or
Changes in fear structures and memory: any other anxiety-related cues, such as distres-
Preattentive biases and early cue-detection of threat sing imagery or worrisome thoughts, are
Associative networks consisting of stimulus and detected and attended to might also be affected
responses propositions Accessibility to network by arousal reduction techniques. In particular,
and imagery techniques that focus on cognitive strategies as a
Changes in associative strengths and meaning means of controlling, for example, worry,
Cognitive avoidance and worry
troublesome imagery, and unpleasant thoughts,
Cognitive change such as guided imagery, autogenics, meditation,
and hypnotic relaxation procedures, might also
Changes in sensation, attributions, and beliefs: have an important role in emotional processing.
Altered subjective experience of tension and calmness Although these techniques may not necessarily
Redistribution of focused attention
Reattributions of anxiety and panic cues/situations
have a direct facilitative role, they may be
Reduction in worry and metacognitions expected to have therapeutic benefits by
Enhanced mastery and coping counteracting other maladaptive cognitive phe-
Commitment to approach and direct exposure of nomena such as worry and disturbing imagery
feared object/situation which, according to Borkovec (1994), inhibit
emotional processing. Worry is said to lead to
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6.10
The Therapeutic Relationship
FRANK M. DATTILIO
University of Pennsylvania School of Medicine, Philadelphia, PA, USA
and
ARTHUR FREEMAN and JOHN BLUE
Philadelphia College of Osteopathic Medicine, PA, USA

6.10.2 THE EXISTENTIAL PERSPECTIVE 231
6.10.3 THE PSYCHOANALYTIC PERSPECTIVE 232
6.10.4 THE HUMANISTIC PERSPECTIVE 236
6.10.5 THE BEHAVIORAL APPROACH 237
6.10.6 THE COGNITIVE-BEHAVIORAL PERSPECTIVE 237
6.10.7 IMPEDIMENTS TO THERAPY 238
6.10.7.1 Definitions of Resistance 239
6.10.7.2 Client Factors 240
6.10.7.3 Therapist Factors 240
6.10.7.4 Problem/Pathology Factors 240
6.10.7.5 Client Factors 240
6.10.7.5.1 Lack of client skill 240
6.10.7.5.2 Client cognitions regarding previous therapy failure 240
6.10.7.5.3 Client cognitions regarding consequences to others change 241
6.10.7.5.4 Secondary gain 241
6.10.7.5.5 Fear of changing 241
6.10.7.5.6 Lack of client motivation 241
6.10.7.5.7 Negative set 241
6.10.7.5.8 Lack of limited motivation 241
6.10.7.5.9 Limited or poor self-monitoring 241
6.10.7.5.10 Limited or poor monitoring of others 241
6.10.7.5.11 Narcissistic style 242
6.10.7.5.12 Client frustrated with lack of therapy progress 242
6.10.7.5.13 Client perception of lowered status in therapy 242
6.10.7.6 Therapist Factors 242
6.10.7.6.1 Lack of therapist skill 242
6.10.7.6.2 Client and therapist distortions are congruent 242
6.10.7.6.3 Poor socialization to the treatment model 242
6.10.7.6.4 Lack of collaboration/alliance 242
6.10.7.6.5 Lack of data 243
6.10.7.6.6 Therapeutic narcissism 243
6.10.7.6.7 Poor timing of interventions 243
6.10.7.6.8 Lack of experience 243
6.10.7.6.9 Therapy goals are unstated, unrealistic, or vague 243
6.10.7.6.10 Lack of agreement with therapy goals 243
229
230 The Therapeutic Relationship
6.10.7.7 Problem/Pathology Factors 244

6.10.7.7.1 Client rigidity foils compliance 244
6.10.7.7.2 Medical/physiological problems 244
6.10.7.7.3 Difficulty in establishing trust and cooperation 244
6.10.7.7.4 Press of autonomy 244
6.10.7.7.5 Impulsivity 244
6.10.7.7.6 Confusion 244
6.10.7.7.7 Limited cognitive ability 244
6.10.7.7.8 Symptom profusion 244
6.10.7.7.9 Dependence 244
6.10.7.7.10 Self-devaluation 244
6.10.7.7.11 Limited energy 245
6.10.7.7.12 Substance use 245
6.10.8 ABUSES OF THE THERAPEUTIC RELATIONSHIP 245
6.10.9 GENERAL GUIDELINES 246
6.10.10 APA CODE 246
The meeting of two personalities is like the contact with a close friend can be summed up in Frank's
of two chemical substances: if there is a reaction, definition of psychotherapy. He states:
both are transformed. (C.G. Jung, 1933)
Psychotherapy is a planned, emotionally charged,
confiding interaction between a trained, socially
6.10.1 INTRODUCTION sanctioned healer and a sufferer. During this
interaction the healer seeks to relieve the sufferer's
Few would argue that the therapeutic relation- distress and disability through symbolic commu-
ship between client and therapist is the corner- nications, primarily words but also sometimes
stone of any psychotherapeutic modality. bodily activities. The healer may or may not
Whether one practices classical psychoanalysis involve the client's relatives and others in the
or radical behaviorism, the practice of psy- healing rituals. Psychotherapy also often includes
chotherapy involves a relationship, an interac- helping the client to accept and endure suffering as
tion, and an emotional exchange between two or an inevitable aspect of life that can be used as an
more individuals. Regardless of whether or not opportunity for personal growth. (Frank, 1985,
the goal is in sight or is directed behavioral p. 50)
change, one cannot ignore the essential ingre-
dient of the bidirectional influence of one party The relationship is not the reason that therapy
to the other within the therapeutic collaboration. can have a helping effect for an individual, but
With each client, the therapist must start from rather the vehicle and context that makes the
the beginning and build a relationship from the probability of relief more likely.
ground up. While the process of relationship This chapter will address four issues of the
building can become well developed over years therapeutic relationship. The first focus will be to
of clinical practice, the therapist learns that each define and compare the view of the therapeutic
and every client requires the same regime. That relationship from different theoretical perspec-
is, to identify the needs of the client, discern the tives, including the Psychodynamic, Existential,
pathways to best relate to the client, and then use Humanistic, and Cognitive-behavioral domains.
those pathways to establish and maintain the The second area of focus will be to relate some of
therapeutic relationship. the empirical data on the therapeutic relation-
The therapeutic relationship has been ad- ship and highlight the correlation between
dressed in the professional literature in a number relationship factors and therapeutic efficacy.
of different manners (Alexander & Luborsky, The third focus will be to identify and describe
1986; Horvath & Greenberg, 1986; Safran & issues and circumstances that negatively impact
Wallner, 1991; Suh, Strupp, & O'Malley, 1986; on the therapeutic relationship, broadly termed
Sullivan, 1954; Wright & Davis, 1994). resistance. Finally, we will address abuses of the
The therapeutic relationship typically in- therapeutic relationship and the impact that
volves factors of confession, atonement and these abuses have on the therapeutic process. A
absolution, encouragement, positive and nega- final summary will attempt to integrate the
tive reinforcement, aversive procedures, beha- factors discussed as well as review some general
vioral modeling, promotion of values, and cheer guidelines for the therapeutic relationship and
leading (Frank, 1985). What makes the ther- the American Psychological Association's code
apeutic relationship different from a long talk for ethical behavior.
The Existential Perspective 231
Early psychoanalytic work identified three undertaking. According to May and Yalom
relational components of the therapy process (1989), existentially oriented therapists strive
that had to be addressed in the therapy. The toward honest, mutually open relationships
meaning, value, and importance of these factors with their clients. The therapist and client
has been the subject of debate for more than 100 address one another equally, generally both on a
years. Nevertheless, we can use them as a broad first-name basis, with the therapist striving
framework upon which to stretch the fabric of toward demystification of the therapy process,
our discussion of the relationship in psychother- answering questions fully and openly, as
apy. These issues were termed transference, opposed to remaining impassive in an effort
countertransference, and resistance. Broadly, to evoke transferential distortions.
they capsule the client's expectations, beliefs, The canon of humanistic existentialism is that
reactions, and responses to the therapist and to the human element must be the focus of the
the therapeutic environment (transference), the therapeutic endeavor. No theory of the person,
therapist's reactions and responses to the of therapy, or of pathogenesis can take
client's transference or, alternatively, the ther- precedence over the personhood and human
apist's reaction to the client generally (counter- elements. Further, those subscribing to a
transference), and the client's difficulty in ªscientific materialistic modalityº as thinking
therapy or avoidance of issues and areas of about client's productions in atomistic terms
concern (resistance). These factors may be such as units of energy, drives, impulses, needs,
overtly expressed or more covertly expressed instincts, stimulus response links, or in
either subtly or symbolically depending on the transformation-of-energy terms lose the essence
particular client and the situation. of the human element. For example, Ofman
(1985) suggests that proponents of psycho-
analysis will be guided by theory rather than by
6.10.2 THE EXISTENTIAL PERSPECTIVE an attention to the person. He explains that the
client should be seen in that (theoretical) light;
Within the context of Existential Therapy the taught that way of thinking (by the analyst); and
therapeutic relationship is one characterized by the client's predictions will be traded in on the
mutual respect, individual uniqueness, authen- ªquotidianº view because it is difficult for
ticity, and pursuit of meaning. According to behavioral scientists to proceed otherwise. In
Seguin (1965), Ìt is through total acceptance, Ofman's view, ªHumanistic existentialism
that the client comes to value his or her own translated that position to dealings with clients,
uniqueness, becomes free to exert choice, to but not in counter transference terms. In such a
make commitments, and to find meaning in translation there is not subject±object split, but
life.º According to Bugental and Sterling there is a mutual processº (p. 12).
(1995), it is necessary to develop what they Within the context of the therapeutic con-
term a `meaningful realistic therapeutic contract/alliance, the existential therapeutic task is
tract.º This suggests an agreement or arrange- the fostering of explicit awareness. The goals are
ment (contract) between the parties and that the for the person to utter, clarify, and identify
individuals involved both contribute and hope projects, and their personal myth; to assume
to gain from the arrangement. The therapeutic ownership and responsibility for one's projects;
contract facilitates understanding between the to validate and embrace both the inevitable
client and therapist, rendering it meaningful and positive and negative aspects of relationships
realistic. Bugental and Sterling (1995) further and of acts, so that the divided, unattended
identify the existence of other therapeutic parts of the personality become integrated. The
functions characterizing the therapeutic course. attainment of such goals leads to greater
Besides developing a meaningful, realistic autonomy, responsibility, and an attendant
therapeutic contract, they propose the impor- equality in relationships. Progress toward these
tance of `Fostering the growth of a resilient goals is sought by means of acceptance,
alliance, working through the situational re- affirmation, and authentic relating between
sistances, working through some of the char- therapist and client (Ofman, 1985). The authen-
acter resistances, exploring client±therapist ticity can occur only when the therapist sees that
collusion (transference±countertransference is- the client has freely chosen to do and to be what
sues), working with residual transferential they are, and to make choices for the best of all
elements and preparing for terminationº possible reasons, personal growth.
(p. 240). The therapeutic contract is viewed as May (1969) states, ªIntentionality presup-
providing a foundation for therapy with the poses an intimate relationship with the world
therapeutic alliance being conceptualized as a that we would not be able to go on existing in
container that will hold the struggles, emotions, except if we could block the world out at times.
and relationships necessary to a major life This should not be called simply by the
condemnatory term `resistance.' I do not doubt disbelief in human goodness and human growth.
the reality of resistance, as Freud and other's Man, he postulated, is doomed to suffer or to
elucidated it, but I am emphasizing here a destroy. The instincts which drive him can only
broader, structural phenomenon. That is èvery be controlled, or at best `sublimated.' My own
intention is an attention, and attention is I-can,' belief is that man has the capacity as well as
as Merleau-Ponty puts it. We are, therefore, the desire to develop his potentialities and
unable to give attention to something until we become a decent human being, and that these
are able in some way to experience an Ì-can' deteriorate if his relationship to others and
with regard to itº(p. 36). hence to himself is, and continues to be, dis-
In essence, the Existential view places a major turbed. I believe that man can change and go on
importance on the development of the relation- changing as long as he livesº (p. 72). Rejecting
ship as central to the therapy. The relationship is Freud's instinctual approach Horney stressed a
famed in terms such as ªrealº or ªauthentic,º stronger contextual stance as influential on the
with the realness of the therapist serving as both individual's development.
a model and guide for the client to emulate. Tasman et al. (1997) make several cogent
points that are important in understanding the
therapeutic relationship:
6.10.3 THE PSYCHOANALYTIC (i) ªHorney believed that humans were not
PERSPECTIVE the tragic figures that Freud depicted, driven by
biological endowment to seek sexual and ag-
Munroe (1955) capsules Karen Horney's gressive satisfaction and inevitably meeting
position by conveying that she believed that conflict.º
man was born a potentially harmonious (ii) ªNormal development was not inherently
organism, capable of expanding his own conflictual. The neurotic child sacrificed the
capacities normally, in happy relationships pursuit of pleasure and the fulfillment of his or
within his surroundings. Conflict, Horney her unique potential which Horney termed the
believed, occurred only as a consequence of real self, to ensure safety in an environment that
social mishandling which instituted exaggerated the child perceived as hostile and dangerous.º
impulses and fears in contradictory directions. (iii) ªUltimately, neuroses was the result of
Normally, a child is confident of help from his the environment; the neurotic child responded
parents, because he has experienced it regularly. to the parents' failure to love her or him as she
The neurotic child believes he must fight for or he was; and neurotic symptoms were im-
everything he wants in a hostile world, because portantly determined by cultural norms.º
he has experienced deprivation. Yet open (iv) ªHer emphasis on the current context of
aggression in a creature as helpless as the analysis has been absorbed into mainstream
human infant brings swift and overwhelming psychoanalysis; her concepts of the real self and
counteraggression. Thus, aggression and the human potential have contributed to the broad-
fear of being aggressive both develop to an er expanse of dynamic psychotherapiesº (p. 96).
exaggerated degree. In the matter of issues directly involving the
One important area addressed by Horney in role of the analyst in the context of the
the therapeutic relationship was her new therapeutic relationship, Horney (1939) writes:
perspective on the psychology of women. ªWhen I feel uncertain about a suggestion made
Tasman, Kay, and Lieberman (1997) identify to the client I point out its tentative character. If
very clearly that it was actually Horney who then my suggestion is not to the point, the fact
ªargued that Freud's model of feminine devel- that the client feels that I too am searching for a
opment was phallocentric, a masculine fantasy solution may elicit his active collaboration in
that protected men from their unconscious fear correcting or qualifying my suggestion.º In
of women. Horney's arguments have been of effect, Horney takes the active position that
central importance in feminist critiques of the analyst should exercise a more deliberate
Freud and ultimately in the reworking of views influence not only on the direction of the client's
of feminine psychology within the mainstream associations but also on those psychic forces
of psychoanalysisº (p. 16). which cause the neuroses but also on those
Horney's therapeutic and theoretical ap- forces that may help him eventually overcome
proach was holistic and placed an emphasis the neuroses. She further states that the work a
upon the notion of self-realization as well as client has to accomplish is most strenuous and
phenomenological and existential influences most painful. It implies no less than relinquish-
noted in her earlier works. Such a position is ing or greatly modifying all the strivings for
characterized by Horney (1945) in the following safety and satisfaction which have hitherto
excerpt: ªFreud's pessimism as regards neuroses prevailed. It implies relinquishing illusions
and their treatment arose from the depths of his about himself which in his eyes have made
The Psychoanalytic Perspective 233
him significant. It also advocates placing his the sum total of all the client's irrational
entire relations to others and to himself on a reactions toward the analyst, not only the
different basis. What drives the client to do this emotional dependence. The problem here is
hard work? Clients come for analytical help not so much why this dependence takes place in
because of different motivations and with analysis, because persons in need of such
different expectations. Most frequently they protection will cling to any physician, social
want to get rid of manifest neurotic distur- worker, friend, member of the family, but why it
bances. Sometimes they wish to be better able to is particularly strong and why it occurs with such
cope with certain situations. Sometimes they frequency. The answer is comparatively simple:
feel arrested in their development and wish to analyzing means, among other things, tackling
overcome a dead point. Very rarely do they defenses built up against anxiety, and thereby
come with the outright hope for more happi- stirring up the anxiety lurking behind the
ness. The strength and constructive value of protecting walls. It is this increase of anxiety
these motivations vary in each client, but all of that causes the client to cling to the analyst in one
them can be actively used in effecting a cure. way or another.º This view is emphasized in the
Tasman et al. (1997) state, ªThe analyst should following comment by Horney (1937). ªSexual
focus on the here and now, interpreting current desires concerning the analyst are usually
wishes and defensive structures so the client's interpreted as repetitions of a sexual fixation
unconflicted potential could emergeº (p. 36). on the father or the mother, but often they are
Concerning Horney's views on the therapist's not genuine sexual wishes at all, but a reaching
and client's direction in therapy, the following out for some reassuring contact to allay anxiety.
excerpt best illuminates Horney's position, ªThe The client, to be sure, often relates associations
aim of therapy is then not to help the client to or dreamsÐexpressing, for example, a wish to lie
gain mastery over his instincts but to lessen his at the mother's breast, or to return to the
anxiety to such an extent that he can dispense wombÐwhich suggest a father or mother
with his `neurotic trends.' Beyond this aim there transference. We must not forget, however, that
looms an entirely new therapeutic goal, which is such an apparent transference may be only the
to restore the individual to himself, to help him form in which a present wish for affection or
regain his spontaneity and find his center of shelter is expressedº (p. 48).
gravity in himselfº (Horney, 1939). In a discussion of issues of transference
In an examination of issues of transference, infatuation, Horney (1937) points out that the
Tasman et al. (1997) explain, ªAlthough child- analyst becomes cognizant of the impersonal
hood influences shaped character, current character of the infatuation and attributes this
defensive needs rather than infantile wishes indiscrimination to the client's tendency to
were the chief determinants of current behavior repeat old patterns. The client feels relieved
and of the client's transference.º Horney (1937) because he/she recognizes that there is some-
states, ªIn relationships in which one person thing compulsory, something not genuine in his/
becomes dependent on the other there is her feelings of love. As a result, the actual
invariably a great deal of resentment. The infatuation diminishes, dependent on the ana-
dependent person resents being enslaved; he lyst's strengths. The client's view may hold that
resents having to comply, but continues to do so his security and satisfaction may depend upon
out of fear of losing the other. When the fear is fastening himself to others or, more accurately,
very great they may seek to protect themselves merging with them. Consequently, giving and
against this dependence by not attaching hopefully obtaining affection is for him, a
themselves to anyone. These processes are means of reassurance and thereby safety.
evident also in a client's attitude during It would seem inconceivable that a therapy
analysisº (p. 24). could begin or proceed without some level of
In a more traditional sense, ªResistance often anxiety being raised for the client. Anxiety may
uses the mechanism of transference as its reflect the need to discuss personal issues and
weapon to interfere with the progress of analysis. problems. It may also involve the need,
In this, the client unconsciously strives to avoid expectation, or requirement that the client relate
the insight which the cure demands. The transfer to the therapist. Whenever anxiety emerges, the
of unconscious infantile wishes to the person of client's need to hang on to the analyst intensifies.
the doctor facilitates their admission into Therefore, whenever the client displays a more
consciousnessº (Eidelberg, 1968). According than usual attachment or transference reaction
to Ferenczi and Rank (1925), the transference to the analyst, the analyst should connect and
is an immediate goal of analysis; the replacement reflect the attachment back to the client as an
of the manifest neurosis by a transference indication of anxiety or insecurity.
neurosis. According to Horney (1937), ªTrans- The effect of this interpretation would be to
ference (in the traditional sense) should refer to open the gate toward a greater recognition on
the client's part, and eventually to lead to an to be desirable? Or do we think of life as a

understanding of the underlying structure process of development which does not end and
responsible for his/her anxiety reaction. As it should not end until the very last day of
is mainly the client's anxiety, according to the existence?
Horneyan view, which makes him dependent The work of Harry Stack Sullivan is, by
on the analyst, interpretations of this kind definition, based on the interaction between
counteract from the beginning the danger of people. His work termed ªInterpersonal Psy-
dependency. chiatryº is representative of the Neo-Freudian
On matters of resistance, Horney (1939) factions of his time that espoused a collection of
contends that when the client is analyzed, he/ ideas that could be found operative within the
she will realize the futility of their efforts, context of the therapeutic relationship. Sullivan
though with some reluctance. He may politely held the belief that human beings possess an
and intellectually follow the analyst's sugges- actualizing tendency, that is to say, an innate
tions that the irritations are only ªbubblesº predisposition for fulfillment of one's human
surfacing. But as soon as the analyst identifies potential. According to Mullahy (1970), Sulli-
one of the deeper disturbances, the client will van believed that there was a built-in tendency
react with a mixture of concealed irritation and of the self to maintain its current organization
diffuse anxiety, and soon will argue most and functional activity. Furthermore, by our
cleverly that the analyst is wrong, that at least very nature we would rather be healthy than to
he is exaggerating his reaction. Resistance for suffer from the pains of mental illness. Sullivan
Horney (1939) involves the energy with which clearly recognized the importance of creativity,
an individual protects repressed feelings or purposefulness, and in stressing a holistic
thoughts against their integration into con- approach in the treatment of his clients.
scious awareness. This concept is based on our May and Yalom (1989) state that in the
knowledge that the client has good reasons for interpersonal model of personality an individual
not acknowledging certain drives and will seek is not instinctually guided and preprogrammed,
to avoid them. but is instead almost entirely shaped by his
Regarding notions of countertransference cultural and interpersonal environment. Hall
and transference, Horney (1939) believes that and Lindzey (1970) regard personality as a
when a therapist reacts with inner irritation to a hypothetical entity which is unable to be
client's tendency to defeat his/her efforts, he/she isolated from interpersonal situations and
may be identifying the client with his/her own interpersonal behavior. It is all that can be
father, and thus repeating an infantile situation observed as personality. In a sense, it is vacuous
in which they felt defeated by the father. If, according to Sullivan to speak of the individual
however, the therapist's emotional reactions are as the object of study because the individual
understood in the light of his/her own character does not and cannot exist apart from his
structure as it is affected by the client's actual relations with other people. Although Sullivan
behavior, then it will be viewed as the therapist's does not deny the importance of heredity and
need to cure every case. Failure to do so may be maturation in forming and shaping the organ-
viewed as a personal humiliation. ism, he contended that, that which is distinctly
In summary, Horney's view states that human is the product of social interactions.
neuroses are ultimately the expression of Some believe that Sullivan's interpersonal
disturbances in human relationships. The psychiatry emphasized psychopathology as a
analytical relationship is a very unique form personal method for coping with terrifying
of human interaction. The therapy then be- relationships. He believed that the therapist as a
comes a microcosm of the client's relational life. participant-observer offered a new mutative
Relationships and existing disturbances are quality of relatedness to the therapeutic rela-
bound to appear in the therapy as they appear tionship (Greenberg & Cheselka, 1995). Sulli-
elsewhere. The particular controlled and con- van believed in experience and cognitive
tained conditions under which an analysis is processes as represented by three modalities:
conducted render it possible to study these the prototaxic, parataxic, and syntaxic modes.
relationship disturbances more accurately than According to Kaplan, Sadock, and Grebb
elsewhere. Finally, the relationship problems in (1994), the prototaxic mode is undifferentiated
the analysis can serve to convince the client of thought that is unable to separate the whole into
their existence and of the role they play in the parts or to use symbols. This is something
forming and maintaining the problems. Kaplan, Sadock, and Grebb believe occurs
At the bottom is the question which is normally in infancy and is also seen in
essential to the goals of therapy. Do we intend schizophrenia.
to put out a finished product with all problems Within the context of the therapeutic relation-
solved for good and all? In fact, do we believe it ship we find that the process is a collaborative
The Psychoanalytic Perspective 235
and active one. According to Kaplan et al. accomplishments of the interview are to ensue
(1994), ªThe therapy process requires the active partly from interpretation of clearly documen-
participation of the therapist, who is known as a ted facts, from the building of inferential bridges
`participant-observer' º (p. 236). Modes of that carry one from particular concrete in-
experience, particularly the parataxic, need to stances to a generalized formulation, and partly
be clarified and new patterns of behavior need from considering alternative hypotheses regard-
to be implemented. In his critical analysis of ing situations in which the client has preferred
Sullivan's works, Mullahy (1970) states that the misleading formulations. It was Sullivan's
therapeutic relationship is a performance of two contentions that psychiatrists, particularly
people, a transaction, in which the client's some psychoanalysts, were prone to interpreta-
behavior and what he says and does are tion of the material expressed by their clients
adjusted, in accordance with the best of his and that the abundance of interpretations was
information and ability, to what he guesses or greatly in excess of the need for them.
surmises about the therapist. In addition, the The therapist, within the context of the
rationale of the interview is based on a therapeutic relationship, seeks to facilitate
progressively unfolding expert client (therapist± identification and awareness of parataxic dis-
client) relationship for the purpose of discover- tortions and the development of insight into
ing the client's characteristic patterns of living. that process.
The therapist seeks to discover those (frequently The notion of resistances were renamed
obscure) patterns of living of the client that he ªsecurity operationsº by Sullivan (1953). He
experiences as particularly troublesome as well felt that the discovery of a parataxic distortion
as those he experiences as particularly valuable. brought about a sharp fall in one's level of
Within the scope of the therapeutic techni- security, causing one to become intensely
ques, interrogation and interpretation warrant anxious. This was viewed as injurious to the
brief definition at this point. It was Sullivan's relationship, and ultimately to the therapy
position to avoid direct interrogation. Sullivan because, ªthe client's self-esteem, his interper-
viewed a direct question in a psychiatric sonal security, is often fragile or at least infirm,
interview as not likely to provoke the most then, the disturbing consciousness of the
informative answer. Rather, Sullivan would `mistake' tends to arouse essentially disintegra-
have the client test out hypotheses that would tive, distance-producing security operationsº
either support or disconfirm his/her existing (p. 34). The therapist must first be aware of the
thoughts on a subject which is more reflective of tendency for this to occur, be skilled in dealing
an indirect approach. Direct interrogative with it, and to then intervene and counter the
questioning was only to be used if there was a disintegrative operation.
very justifiable reason and purpose. Mullahy For Sullivan, counter transference (in the
(1970) writes, ªThe interrogation proceeds from classical Freudian sense) was the result of
a given point in a direction that is easy for a inadequate skill or some personal inadequacy
client to followº (p. 16). Regarding the use of (Mullahy, 1970). Sullivan did not believe a
interpretations, they must be timely and therapist should become seriously ego-involved
accurate as well as and constructive. Further with a client, and would, in fact, consider any
interpretation as a therapeutic strategy if used personal involvement with his client therapeu-
inappropriately might serve to fuel anxiety. tically dangerous and part of what he termed
According to Mullahy (1970), one must usually ªsocial hokum.º For Sullivan, the key to the
avoid questions and interpretations that arouse effectiveness of therapy was the interpersonal
anxiety since, among other things, it provokes relationship. He saw the therapist as an expert in
aspects that interfere with growth of the client's the problems that ªailº the client but did not
information and insight. Clearly if an untimely recommend that the therapist become intimate
inappropriate interpretation is made and results with any of them.
in an unnecessary escalation of the client's Sullivan expanded upon and reformulated
anxiety, the therapeutic relationship could fall the notion of transference in terms of parataxic
into serious jeopardy. Sullivan was aware that at ªme±youº patterns. He interpreted transference
times anxiety could serve a constructive func- as a one-way process that showed the direct
tion when it helped to mobilize a client. In interaction of personalities. ªBy transference
general, however, he viewed it as a ªformidable the client manifests interpersonal processes that
enemyº (Mullahy, 1970). open the gates of memory sealed by dissocia-
In reading Sullivan's works, one can see that tions, reorients his experience, and facilitates the
his methodology represents an honest attempt development of arrested or distorted systems of
at scientific inquiry. It is clear that his motives so that he moves forward toward the
psychiatric interview is an attempt at the conditions of adult personality organizationº
collection of relevant data. The results or (Sullivan, 1962, p. 87).
In the initial stages of the therapeutic relation- ality change in a client. Basically, the therapist
ship the therapist has the responsibility when the uses himself/herself within the relationship as an
client presents a problem, especially in the early instrument of change. Hence, encountering the
stages of therapy, to not arouse so much anxiety client on a person-to-person level, their role as a
that the client feels threatened. This would occur therapist is actually to be ªwithout a role.º The
before a client learned how to withstand a good main function then is to establish a therapeutic
deal of anxiety when experiencing any perceived climate that helps the client grow in an
attack on their self-esteem. In the initial stages of individual way.
the therapeutic relationship, the therapist must The therapist's role becomes essential in the
ensure within the structure of the therapeutic person-centered modality in that it creates a
situations that both the therapist and client can helping relationship in which clients experience
arrive at an agreement on the overall goal, end, the necessary freedom to explore areas of their
or inclusive ªpurposeº of the therapy, so that life that are now either denied awareness or
there is collaboration. distorted. A genuine aspect of the therapist's
Mullahy (1970) identifies that ªSullivan held role involves the willingness to be real in the
that in the course of identifying all the more relationship wih a client instead of viewing him/
parataxically `surviving,' unresolved situations her in a preconceived diagnostic fashion. In
of the client's past and their consequent essence, the relationship then meets the client on
dissolutions, there progressively occurs an a moment-to-moment experiential basis in an
expanding of the self to the extent that the attempt to help them divulge their world. It is
client as known to himself is much of the same through the therapist's relationship of genuine
person as the client behaving with others. This caring, respect, acceptance, and understanding
was, for Sullivan, the therapeutic cure. Ideally, that they are able to help the client loosen their
the client would achieve social cure (though not defense mechanisms and rigid perceptions in
always the outcome) that might bring about a order to evolve into a level of personal
more abundant life in the community.º functioning.
In his early work, Rogers (1961) wrote ªIf I
can provide a certain type of relationship, the
6.10.4 THE HUMANISTIC PERSPECTIVE other person will discover within himself or
herself the capacity to use that relationship for
A discussion of the therapeutic relationship growth and change, and personal development
would not be complete without addressing Carl will occurº (p. 33). It was Rogers' contention
Rogers and his person-centered approach. that the significant positive personality change
Rogers was a major spokesman for the of an individual occurs only as a result of the
humanistic movement in psychology and led a relationship between therapist and client.
personal life that reflected the ideas that he The characteristics of the therapeutic rela-
developed and used in his psychotherapeutic tionship that are conducive to creating a suitable
approach. psychological climate involve creating an atmo-
He displayed a questioning stance and a deep sphere in which the client will experience the
openness to change which spiraled person- necessity to initiate personalty change.
centered therapy to a height of becoming a Rogers believed that the following six con-
major force in psychology. ditions were necessary and sufficient for
The goals of person-centered therapy differ personality changes to occur:
from those of traditional approaches. The (i) Two persons are in psychological contact.
person-centered approach aims toward a great- (ii) The first, whom we shall term the client, is
er degree of independence and integration of the experiencing incongruency.
individual in treatment. Its focus is on the (iii) The second person, whom we shall term
person, not on the person's presenting problem. the therapist, is congruent or integrated in the
Rogers (1977) contends that his aim of therapy relationship
is not merely to solve problems, but to assist (iv) The therapist experiences unconditional
clients in their growth process so that they can positive regard or real caring and acceptance for
better cope with problems they are currently the client.
facing as well as deal with future issues. (v) The therapist experiences an empathic
The specific role of the person-centered understanding of the client's internal frame of
therapist is rooted in their ways of being and reference and endeavors to communicate this
attitudes, not techniques designed to get the experience to the client.
client to do something to change. Research on (vi) The communication to the client or
person-centered therapy indicates that the the therapist's empathic understanding and
attitudes of therapists, rather than their knowl- unconditional positive regard is to a minimal
edge, theories, or techniques, facilitate person- degree achieved (Rogers, 1987, pp. 39±41).
The Cognitive-behavioral Perspective 237
Rogers hypothesized that no other conditions clients, the therapeutic relationship is impor-
were necessary to facilitate change in the ther- tant. Behavior therapists tend to be more active
apeutic relationship. He believed that if the and directive and can function as consultants in
aforementioned six conditions occurred over a helping the client solve problems as opposed to
given period of time, constructive personality allowing the relationship in and of itself to
change would occur. facilitate the change. Since behavior therapists
In addition, three personal characteristics, or use a coping model in initiating behavioral
attitudes, of the therapist form the central part change in the clients natural environment, it is
of the therapeutic relationship. These include important that they be personally supportive to
congruence, or genuineness, unconditional them. However, once again the actual process of
positive regard and acceptance, and accurate change comes from the implementation of
empathic understanding. techniques as opposed to a byproduct of the
One final important aspect of Rogers' work actual relationship. At the very least, behavior
was that he believed that the therapist and the tharapists view the relationship as being an
person of the therapist were the same individual. important supportive aspect, yet not necessarily
He believed that therapists should live their lives essential to change.
in accordance with theory which is used in the
course of psychotherapy. Rogers believed this
to be paramount in the therapeutic relationship. 6.10.6 THE COGNITIVE-BEHAVIORAL
PERSPECTIVE
6.10.5 THE BEHAVIORAL APPROACH Despite criticism by some in the field,

cognitive-behavior therapy places an important
Clinical and research evidence suggests that a emphasis on the therapeutic relationship as an
therapeutic relationship, even in the context of a integral part of the effectiveness in the treatment
behavioral orientation, can contribute signifi- process. Constructs from cognitive-behavioral
cantly to the process of behavior change therapy can be used to understand variability in
(Granvold & Wodarski, 1994). A good ther- client behavior, and cognitive-behavioral for-
apeutic relationship increases the chances that mulations can be used to guide individuals in
the client will be receptive to therapy. Not only dealing with difficult problems in the therapeu-
is it important for the client to cooperate with tic relationship. What is more, vicissitudes in the
the therapeutic procedures, but the client's therapeutic relationship can provide individuals
positive expectations about the effectiveness of with an opportunity to work directly with
therapy may often contribute to successful clients' most significant maladaptive schemas
outcomes as well. The behavior therapist is which are an essential part of the therapeutic
one who can conceptualize problems behavio- relationship. Schemas are defined as cognitive
rally and make use of the client/therapist structures that may be at the core of an
relationship in facilitating change. individual's particular dysfunction. It is a
As opposed to some of the other modalities of maladaptive, cognitive±interpersonal cycle that
treatment, behavioral practitioners do not clients' perceptions of the therapist's behavior
assign an all important role to relationship provide a phenomonological link to the dys-
variables. Instead, they typically contend that functional interpersonal schemas and asso-
factors such as warmth, empathy, authenticity, ciated patterns of behavior (Safran, 1990;
permissiveness, and acceptance are considered Safran & Segal, 1990).
necessary, however, not sufficient for behavior- The notion of an individual's maladaptive
al change to occur (Bandura, 1977). It is not a beliefs or schema was first proported by Beck,
matter of the importance of the relationship per Rush, Shaw, and Emery (1979). Schemas, which
se, but rather the role of the relationship as a are cognitive distortions at the individual's
foundation on which therapeutic strategies are deepest level, consist of concepts that the client
built to help clients change in the direction that habitually uses in viewing reality. These biases
they desire. Lazarus (1989) maintains that direct their focus in the retrieval of information.
unless clients respect their therapist it will be Typical negative schemas include rejection,
difficult to develop the trust necessary for them abandonment, control, uniqueness, and unre-
to engage in significant self-disclosure. At the lenting standardsÐprime aspects that are found
same time therapists need an array of clinical in any therapeutic relationship.
skills and techniques to employ once an effective Therefore, a client who may maintain a
client/therapist relationship has been estab- negative schema of rejection will tend to focus
lished. Since behavior therapy demands such on any sign that he or she is being rejected by the
a high level of skills and sensitivity as well as the therapist. The same goes for their concept of
ability to form a working relationship with abandonment and consists of what may be
defined by the specific bias of their content. but in accordance with the complexity or the
These schemas are usually formed during early problem itself. The more specific and simple the
childhood and selectively focus on information problem, the more the therapeutic relation shall
processing. be of less importance. Results from a series of
In his cognitive model, Beck, Freeman and investigations give evidence to the importance
associates (1990) used personality as a combi- that the therapeutic relation has gained as an
nation of core beliefs and a characteristic set of instrument of social change. Sloan (1975) found
basic strategies for interacting with others. that consultants who solved their problems
Inter-related beliefs and action plans are satisfactorily through behavioral therapy con-
organized within a generic knowledge structure sidered the relation with their therapist as the
referred to in the cognitive literature as schema. most important factor in their recovery.
These schemas guide and actively participate in Alexander (1976) reports that the therapeutic
the processing of information and actions so relationship contributed significantly to the
that we see recurring patterns of thoughts, behavioral treatment of delinquents and their
feelings, and behaviors. families. Mathews et al. (1976) found that a
When deeply held beliefs and well-ingrained group of agoraphobics considered that the
behavioral patterns are repeated in the ther- support, enthusiasm, and sympathy received
apeutic relationship and interfere with the from their therapist helped them to overcome
effective use of what cognitive therapists refer their fears more than the actual practice of
to as collaborative empiricism, this creates a exposure exercises. Researchers Orlinsky and
threat in the therapeutic process. The clients' Howard carried out a revision in 1986 about
expectations and perceptions of the therapist research undertaken in order to study the
are typically distorted to remain consistent with predictive capacity for diverse factors in
his/her underlying beliefs. Behavior also re- psychotherapy with regard to their efficiency.
mains consistent with dysfunctional beliefs. They were surprised by the great predictive
Cognitive-behavior therapists state that ªcog- capacity shown by patients' feelings about the
nitive transference develops when the afore- empathy shown by the therapist. This prediction
mentioned patterns are repeated in the went far beyond what could be done based on
therapeutic process (Wright & Davis, 1994). the empathy displayed by the therapist. In
Cognitive-behavior therapists typically use general, these results suggest that the inter-
certain procedures to identify and modify pretation which the client has on the actions of
maladaptive beliefs and dysfunctional behavior the therapist during treatment is a significant
when cognitive transference occurs. When an factor in the effectiveness of the respective
individual has a serious personality disorder, treatment. The therapeutic relationship may
this process may require longer-term therapy therefore be used as a process facilitator of
than is usually the case with a major depressive social influence of different forms.
or anxiety disorder. In summary, the therapeutic relationship is an
The examination of beliefs, related behavioral essential, interactive component of the process
strategies, and patterns in the therapeutic of cognitive-behavior therapy. Cognitive-beha-
relationship can help therapists recognize and vior therapists need to remain sensitive to both
manage each client's unique expectations within the general and idiosyncratic expectations of
the therapeutic process. It is extremely impor- their clients, without compromising the neces-
tant that this be done and addressed forthright sary limits or boundaries of the relationship. It is
since any schema level analysis that is ignored attention to these principles that will aid in
may contribute to the clients' resistance and building productive therapeutic relationships.
noncompliance and thwart the progress in
therapy. In addition, excessive dependency or
stagnation in the treatment process may also 6.10.7 IMPEDIMENTS TO THERAPY
occur.
It is therefore that cognitive-behavior thera- It is tempting (and simplistic) to blame
pists emphasize the intense supervision on treatment difficulty or lack of progress in
relationship issues in training programs (Mi- therapy on the client's noncompliance or
chenbaum & Turk, 1987). In fact, it has been ªresistance.º Therapists may assume that when
suggested that this element of the therapeutic progress lags it is because the client does not
process should require as much attention as want to change or ªget well,º for either
learning how to implement specific cognitive conscious or unconscious reasons. However,
and behavioral techniques (Wright & Davis, there are many different problems which can
1994). slow or block progress in therapy and few of
The degree of importance of the therapeutic them are due to the client's desire to retain his or
relationship depends not only on the approach, her problems. To illustrate this point, one might
Impediments to Therapy 239
consider a ªself-helpº or ªself-improvementº resistance, for example, trying to win the

task such as losing weight, exercising regularly, therapist over with praise, gifts, or devotion.
or completing unfinished paperwork which one Resistance may be conscious, for example,
has been slow to complete. Is the lack of follow- withholding information and details to appear
through due to a secret desire to remain healthier, smarter, and so on. On the other
overweight, out of shape, or behind in paper- hand, the same material might not be reported
work, and to what extent might it be due to a because of ªforgetting,º a process that might be
number of more mundane factors such as more unconscious.
personal comfort, time limitations, and so on. A starting point for understanding resistance
Might it be viable to assume that sometimes it is is to conceptualize it as a normal and adaptive
a combination of the two? response to any type of perceived threat.
Whether the resistant behavior is viewed as
an ego defense or as a response to unfamiliar
6.10.7.1 Definitions of Resistance demands, it is unreasonable to accept that an
individual will move directly to change without
Common themes of client resistance in some level of discomfort. In point of fact, an
therapy involves distrust of the therapist, individual who moves too quickly to change
personal shame, grievances against others, may be seen as impulsive or labile. An extreme
depreciation, or fear of rejection. Typically, to this would be the client with a borderline
resistance may be manifested directly (e.g., personality disorder who moves quickly from
tardiness or missing of appointments) or more overidealization to complete devaluation. Nor-
subtly through omissions in the material mally, there is initially some hesitation with
reported in the sessions. A number of publica- this process. Such resistance needs to be
tions have addressed this important issue (Ellis, identified and addressed directly within the
1985; Shelton & Levy, 1981; Stark, 1994; therapy process. Resistance is a predictable and
Wachtel, 1982). There are, however, many therefore expected and at times even welcome
reasons for noncompliance other than the client part of the therapy. It can become an arena for
not wanting to change or the lack of compliance the practice of a range of therapeutic inter-
indicating a pitched battle between intrapsychic ventions and in some cases adds to the change
structures. process.
Clinically, we can identify several reasons for Many of our clients have been involved in
noncompliance. They can appear in any therapy prior to submitting to their present
combination or permutation, and the relative course of treatment. If the previous therapeutic
strength of any noncompliant action may experience has not been successful, it might be
change with the client's life circumstance, essential for the therapist to first assess what
progress in therapy, relationship with the occurred in the previous therapy in terms of the
therapist, and so on. We can divide these focus, direction, content, timing, cadence, and
impediments to therapy into four broad style of treatment. With this information in
categories. The first are problems emanating hand, the therapist can then work to alter any
from the client. The second category include and all of the factors emblematic of the previous
those problems stemming directly from the therapy so that the present therapy is experi-
therapist. The third category pertains to those enced as different, and not more of the same old
attributes involving the type, severity, and pattern. For example, if the previous therapy
nature of the client's problem(s) or diagnosis. was unstructured, structure would offer a
The final factors are those related to the client's different therapeutic experience and possibly
life situation, personal context, and significant draw forth new or different material. If the
others. For each problem discussed, we will content revolved around a particular issue
describe therapeutic interventions for reducing shifting to a variant of that issue, or even a
or ameliorating these obstacles and impedi- different issue may be in order. The use of
ments to therapeutic change. different examples would be useful in this
Resistance or noncompliance may take many regard. The short-term treatment approach is
forms. Some would appear more directly often enough of a different focus to make the
negative, for example, verbal evasion, verbal therapy a new experience and opportunity for
or physical aggression, or threats against the change. If the previous therapy was unstruc-
therapist or agency. Other forms of resistance tured, structure would be helpful. If the
may be more subtle, for example, lateness for previous therapy was a short-term treatment
appointments, missing appointments, extended approach, the therapist must be even more
silence in sessions, forgetting homework, or creative in finding new directions or foci.
failing to pay the therapist's bill. And yet, others Use of the broad umbrella term of resistance
may appear positive, but still have the effect of may do more to limit therapy than to encourage
or support it. Several reasons for noncompli- 6.10.7.5 Client Factors

ance with a given therapeutic regimen may be
6.10.7.5.1 Lack of client skill
isolated. It would be impossible to totally isolate
each one as a separate and completely distinct Therapists cannot make the assumption that
entity from all others. There will, of necessity, be every client has developed the skills to effectively
similarity and overlap. To make it easier to perform a particular behavior or sequence of
identify and deal with each, we have divided behaviors. For many clients their difficulty in
them into three categories, client factors, therapy will parallel their inability to cope with
therapist factors, and problem or pathology life stressors. Both may be based on inade-
factors. quately developed skills. These skills may be
broad, that is, social skills, or more discrete, that
is, making eye contact while speaking to another
6.10.7.2 Client Factors person. For many individuals, their skills may be
(i) Lack of client skill adequate for ªgetting byº in familiar and highly
(ii) Client cognitions regarding previous structured areas of life experience, when their
therapy failure skills are tested in novel situations they have far
(iii) Client cognitions regarding conse- more difficulty and may withdraw, or fail. If
quences to others of change however, they are overtly successful at coping,
(iv) Secondary gain they experience such a high level of discomfort
(v) Fear of changing that they will avoid future encounters. Given
(vi) Lack of client motivation that the client may never have developed skills,
(vii) Negative set or not developed them to the level necessary for
(viii) Limited or poor self-monitoring adequate functioning, the therapist may need to
(ix) Limited or poor monitoring of others teach particular skills to help the client move
(x) Narcissistic style along in therapy and thereby in life.
(xi) Client frustrated with lack of therapy
progress 6.10.7.5.2 Client cognitions regarding previous
(xii) Patent perception of lowered status in therapy failure
therapy.
When the client has cognitions of failing to be
able to successfully make changes in thought or
6.10.7.3 Therapist Factors behavior, the therapist needs to help the client to
carefully examine their cognitions. Examining
(i) Lack of therapist skill the cognitions, the underlying assumptions/
(ii) Client and therapist distortions are con- schema and learning to respond in an adaptive
gruent manner to these negative and self-deprecatory
(iii) Poor socialization to the model thoughts, is a major goal of the therapy work.
(iv) Lack of collaboration/alliance One aspect of ªfailureº which inhibits many
(v) Lack of data clients is their anticipation regarding the
(vi) Therapeutic narcissism therapist's reaction if homework assignments
(vii) Poor timing of interventions are not done ªright.º If the client anticipates
(viii) Lack of experience receiving harsh criticism, anger, expressions of
(ix) Therapy goals are unstated, unrealistic, disappointment, or other aversive responses
or vague from the therapist when the homework is
(x) Lack of agreement with therapy goals. discussed, this can easily result in his or her
avoiding the homework and coming up with
6.10.7.4 Problem/Pathology Factors excuses for not having done it. Obviously, it is
important for the therapist to respond to
(i) Client rigidity foils compliance noncompliance without being punitive or
(ii) Medical/physiological problems authoritarian and instead to work with the
(iii) Difficulty in establishing trust client to understand what blocked compliance.
(iv) Autonomy press However, it is also important for the therapist to
(v) Impulsivity be alert for negative anticipation based on the
(vi) Confusion client's previous experience with parents and
(vii) Limited cognitive ability teachers and to address these explicitly if they
(viii) Symptom profusion impede therapy. In particular, perfectionistic
(ix) Dependence clients often anticipate extreme reactions if the
(x) Self-devaluation homework is not done perfectly, and it can be
(xi) Limited energy quite useful to address these anticipations early
(xii) Dissociation. in therapy.
Usually it is possible to honestly present the 6.10.7.5.6 Lack of client motivation

client's task as a ªno-loseº situation by pointing
Clients may arrive for therapy under protest.
out to the client that incidents of noncompliance
Therapy may be mandated as part of a legal
or unexpected results provide opportunities for
penalty, that is, ªgo to therapy or go to jail.º For
making valuable discoveries. For example, the
other clients, therapy is coerced by family
therapist might follow the first homework
members, that is, ªIf you don't get help, I'm
assignment with, ªOne of the nice things about
leaving you.º For child and adolescent clients,
this sort of approach is that whatever happens,
the referral will come from the school or
we come out ahead. If you go ahead and do [the
parents, that is, ªYou are in trouble and must
assignment] and it goes the way we expect, great!
change what you are doing, now.º
We're making progress towards your goals. If
In these circumstances, clients come to
you unexpectedly cannot get yourself to do it or
therapy with the message that the therapist is
if it does not work out the way we expect, then
an agent of the referring (or coercive) indivi-
we have an opportunity to look at what
dual, whether that individual is parent, spouse,
happened and at your thoughts and feelings
judge, probation officer, guidance counselor, or
to discover more about what blocks you from
teacher. This may facilitate an adversarial
your goals. If it goes smoothly we're making
situation prior to the first therapy session,
progress and if it doesn't, we're making a
setting the stage for possible failure.
discovery.º For many clients this greatly
reduces the fear of failure.
6.10.7.5.7 Negative set
Often a client is seen to have a ªbad attitude,º
6.10.7.5.3 Client cognitions regarding
or ªa very negative view.º What is labeled as
consequences to others change
negative or attitudinal is often an issue of
Another set of cognitions involves the client negative set. The negative set might be
having catastrophic ideas relative to the result of manifested directly as ªYes-butº behavior
their attempting to change on others. The client quickly disqualifying whatever the therapist
often catastrophizes the result or consequences says, or as directly arguing with the therapist on
of their changing and needs to not only issues both large and small.
decatastrophize the potential, but to examine
whether there are still advantages to changing.
6.10.7.5.8 Lack of limited motivation
The reason for referral, the reasons offered
6.10.7.5.4 Secondary gain
for the client to change, the client's comfort or
There may be situations where the client may limited discomfort with behaving and feeling
not change because of the gain that accrues from the way that they do, the level of dysfunction,
continuing their dysfunctional suicidal thinking and the press of demands of significant others
and/or behavior. In the case of suicidal behavior all may work to reduce motivation. Often, the
or ideation, this may force family members to client may see small parts of the problems, but
treat the client with ªkid gloves,º not put any perceives them as ªpart of them,º or as too small
pressure on the client, avoid confrontation, and to bother with in therapy. The demands of
generally allow the client to do whatever they therapy, cost, time, money and effort all further
wished, rather than increase the suicidal poten- contribute to the limiting of motivation.
tial. This gain may be obtained from family,
friends, employers, or other individuals with
6.10.7.5.9 Limited or poor self-monitoring
whom the client has interaction. This client needs
to look at the ªprimary lossº that goes into Individuals may see the flaws and foibles of
achieving their secondary gain. The client needs others, but remain blind to their own. Difficulty
to be helped to achieve their gain in other ways. or inability to self-monitor will often be a major
stumbling block to therapy. Being either
unaware or unable to self-monitor and to then
6.10.7.5.5 Fear of changing
self-evaluate will lead to depressive affect and
For some clients, changing means relinquish- behavior. The client will often not self-monitor
ing ideas, beliefs, or behaviors that they see as but will self-devaluate by developing and
inimical to their survival. While this may appear maintaining negative ideas about themselves.
paradoxical in that their thinking makes them
suicidal, these clients fear change as an
6.10.7.5.10 Limited or poor monitoring of others
unknown. They often choose the familiarity
of their pain to the uncertainty of a new mode of For some clients, the monitoring of others is a
thinking or behaving. problem. They tend to look at others, but see
very little. Their response to others would more therapist, no matter what their training. If the
likely be based on the client's images and therapist's skills are poorly developed to
distortions of others rather than a databased effectively cope with a problem, transfer to
assessment. They will often see others as another therapist is the ethical requirement.
brighter, more attractive, more skilled, and so
on. They will view all other relationships as
6.10.7.6.2 Client and therapist distortions are
more rewarding than any they have or might
congruent
have, and do not seem to open their eyes to
collect the needed data regarding others. This therapist blind-spot may be very
destructive to the therapeutic process in that
it would generally incline the therapist to accept
6.10.7.5.11 Narcissistic style the client's dysfunctional beliefs. If client and
A narcissistic style needs to be differentiated therapist share a particular dysfunctional idea,
from a diagnosis of clinical narcissism. The for example, ªeverything is hopeless and cannot
narcissistic style causes the client to be so self- change,º it will bode poorly for the therapy.
involved that any attempt to have them look at This sharing of an idea or belief can result in the
others or at themselves is met with resistance. therapist ªbuying intoº the client's hopeless
The reaction is typically framed as, ªIt can't be ideas and beliefs, not testing these beliefs, or
me,º or ªWhy would you (or anyone) expect so even encouraging them.
much from me.º
6.10.7.6.3 Poor socialization to the treatment
6.10.7.5.12 Client frustrated with lack of model
therapy progress The client who does not understand what is
Clients may have unrealistic expectations of expected of them will have difficulty complying
therapy and possible therapy progress. When with the therapeutic regimen. It is essential that
the expectations are not met, the client may the therapist assess the level of understanding of
blame self or therapist for the lack of therapy the model throughout the therapy work,
progress and withdraw or withhold from the especially with the suicidal client. Often their
therapeutic collaboration. ability to listen and understand may be impaired
by their hopelessness. The therapist cannot
assume that having read books about therapy
6.10.7.5.13 Client perception of lowered status in guarantees adequate socialization to therapy.
therapy Further, there may be proactive interference
For some individuals, being a client is a mark because of previous therapy. Clients who have
of lowered status. For many, being in therapy is been in therapy have, ideally, been socialized to
the mark of being ªsick,º ªdisturbed,º ªweird,º that previous therapy model. They will continue
or ªcrazy.º Given that belief, it would follow to use the same strategies and approach to
that leaving or avoiding therapy makes one less therapy and to life in general unless and until
of all of the above. they are taught differently.
6.10.7.6 Therapist Factors 6.10.7.6.4 Lack of collaboration/alliance

Collaboration is an essential ingredient for all
6.10.7.6.1 Lack of therapist skill
psychotherapy. This is crucial in working with
Just as clients come into therapy with a the suicidal client. If the client and therapist do
particular set of skills, so too do therapists. not have a good working alliance, it would seem
Because of limited experience with a particular to follow that the client may be less motivated to
client problem or population, the therapist may work with the therapist, do homework, follow
not be best equipped to work with a particular the therapist's direction, or generally work
client. The therapist working within the context towards making changes. The lack of collabora-
of an agency or hospital setting may be able to tion, if not based on socialization difficulty or
call in colleagues for consultation on the case or the skill of the therapist, may be due to the
to seek supervision on the particular case/ client's cognitions relative to cooperation or
problem. It would be incumbent upon therapists collaboration. Certain clients may actively work
to constantly develop, enhance, and upgrade to thwart the therapist. This type of passive±
their skills through additional training. Post- aggressive behavior may be motivated by any of
graduate courses, continuing education pro- a variety of client cognitions, that is, issues of
grams, seminars, workshops, or institutes would control, fear, competition, or displaced anger
be part of the professional growth of the may all serve to cause difficulty in the therapy.
This client may be directly challenging or more appearing to be noncompliant. If the therapist,
covertly avoidant as in the classic ªyes, BUTº because of his or her anxiety, tries to push or
response. rush the client, the result may be the loss of
For example, a therapist in training asked for collaboration, the missing of sessions, a mis-
advice in handling a client's noncompliance understanding of the therapeutic issues, or a
with behavioral experiments designed to reduce premature termination of therapy, a possibly
the client's perfectionism. The client's goals for fatal issue with a hopeless client.
therapy were to resolve some relatively minor The timing and pacing of interventions can be
marital problems, but the therapist saw the quite important. If the therapist tries to push or
client's perfectionism and the stress and job rush the client, the result may be the loss of
dissatisfaction which resulted from it as more collaboration, poor compliance, poor atten-
significant problems. Rather than discussing dance, or premature termination of therapy.
this issue with the client and reaching an
agreement on the goals of therapy, the therapist
had unilaterally begun working on perfection- 6.10.7.6.8 Lack of experience
ism and this led to the noncompliance.
Collaboration involves both the therapist and Inexperience is something that all therapists
the client and either of them can disrupt it. If the face at the advent of their careers. This
client feels that he or she has no voice in how impediment is unintentional and a standard
therapy proceeds, either because this is indeed part of the mental health training system. Front-
the case or because of his or her beliefs and line therapists working with the most disturbed
expectations, this is likely to interfere with and problematic clients may be therapists in
collaboration and produce problems with practicum, internship, or residency settings.
compliance. It is important for the therapist
to actively solicit and value the client's input in
setting agendas, determining the focus of 6.10.7.6.9 Therapy goals are unstated,
therapy, and developing homework assign- unrealistic, or vague
ments, particularly with clients who tend to When the goals of therapy are unstated,
be unassertive. It is also important to be alert for unrealistic, or vague, the client may be in the
any cognitions on the part of the client which position of unknowingly resisting the treatment.
could block collaboration. This issue also raises problems with informed
consent. The client must be part of the treatment
6.10.7.6.5 Lack of data planning process and informed as to the goals,
strategies, and interventions of the therapy so
The basis for treatment is the assessment and that they can best comply rather than being
general collection of data. The therapeutic noncompliant out of ignorance.
conceptualization and the resultant treatment
plan is then databased. If the therapy is focused
on theory without data, the therapy will suffer.
6.10.7.6.10 Lack of agreement with therapy
The therapist may then make major conceptual
goals
leaps without a solid footing upon which to base
the therapy. Obviously, the client who does not under-
stand and agree to what is expected of him or
her will have difficulty complying with the
6.10.7.6.6 Therapeutic narcissism
therapeutic regimen. However, it is easy for
An issue that can be a major impediment to therapists to overlook the possibility that their
therapy is what we term ªtherapeutic narcis- instructions and explanations may not be
sism.º This results from the therapist being so understood and accepted by the client. It is
taken with themselves that they are blinded by important for the therapist to repeatedly solicit
the need for greater humanity and empathy. The feedback from the client and to encourage the
therapeutic narcissism may take the form of client to raise any concerns and objections, so
telling rather than asking the client how they that therapist and client can develop a shared
feel. It may take the form of deciding what the understanding of the client's problems which
client needs without consulting the client. forms a basis for collaboration and so that it is
clear that the client understands and accepts the
homework assignments. Generally this proves
6.10.7.6.7 Poor timing of interventions
to be sufficient, but when the client holds strong
Interventions that are untimely can have the preconceptions about therapy, the therapist
effect of the client not seeing the importance or may need to compromise to some extent in
relevance of the therapeutic work, and thereby order to facilitate collaboration.
6.10.7.7 Problem/Pathology Factors 6.10.7.7.6 Confusion

6.10.7.7.1 Client rigidity foils compliance Clients who are confused because of schizo-
phrenia, bipolar illness, or neurological injury
With some clients, their personality rigidity
or deficit will have difficulty making use of
foils their ability to actively comply with
therapy. They may have memory problems,
therapy. This is particularly true with clients
difficulty in follow-through, difficulty with
who are obsessive-compulsive, paranoid,
homework, and problems dealing with any
among others, in which their disorder may
abstractions.
preclude their compliance. They may question
the therapist's motives or goals. They may be
unable to break out of the rigid position that 6.10.7.7.7 Limited cognitive ability
they see themselves as having to maintain.
Clients may have limited cognitive ability that
is a result of limited intellectual ability or neuro-
6.10.7.7.2 Medical/physiological problems logical deficit. Their processing will be limited by
It is essential for every client coming for the lowered level of cognitive integration.
therapy to have a complete medical evaluation,
with blood work as part of a comprehensive 6.10.7.7.8 Symptom profusion
assessment and treatment plan. It is unethical
and dangerous for the therapist to be treating Anxious clients will often overwhelm the
what may appear to be psychological disorders therapist with graphic, elaborate, and detailed
but have a medical etiology, for example, a descriptions of their symptoms. Their idea is
client with hypothyroidism may appear de- that if anything is left out they run the risk that
pressed because of the slowed action and the omitted piece will be the essential piece that
thinking. Conversely, hyperthyroidism might makes it impossible for them to be helped. If
be confused with anxiety disorders. part of their symptom picture is gastrointestinal
distress, they will regale the therapist with
images of their distress. The therapist will
6.10.7.7.3 Difficulty in establishing trust and quickly learn more about the clients gastro-
cooperation intestinal tract than is necessary. They will often
Trust is a central issue in therapy. The trust avoid therapy by speaking quickly to get it all in.
must be bidirectional where the client trusts the
therapist and the therapist can trust the client. 6.10.7.7.9 Dependence
For clients where problems of trust are a
diagnostic part of the disorder will have The client who is dependent will often work to
problems in therapy. insure that the therapist is totally and com-
pletely on their side. They may overwhelm the
therapist with data, bring the therapist gifts, or
6.10.7.7.4 Press of autonomy praise the therapist for the wit, insight,
The autonomous individual will be reluctant sensitivity, and perspicacity. The goal is close-
to come for therapy. Their view is that if they ness. Without the closeness, they believe that
cannot help themselves, how can anyone else they will be injured or even destroyed. They are
help them. The idea of coming to someone's often frightened by short term therapy in that it
office at a time set by someone else's schedule, to means that in a relatively short time they will be
talk about themselves is, at best, uncomfortable. without their helper.
Their avoidance of therapy is seen as one way of
maintaining their autonomy.
6.10.7.7.10 Self-devaluation
Often termed low self-esteem or poor self-
6.10.7.7.5 Impulsivity
image, this involves devaluing everything that
Clients who are impulsive, and this includes one does, or the concomitant overvaluing of
most children and adolescents, see therapy as what everyone else does (and therefore by
restrictive and limiting. At best it is out of line comparison devaluing self). This often leads to
with how they generally respond, at worst the ªyes-butº behavior and to devaluing both the
therapy is seen as an onerous and problematic therapy and the therapist. This devaluation can
requirement that they cannot meet. Their be summed up by paraphrasing Groucho
standard and accustomed manner of response Marx's comment, ªI would never join any club
is to act without thinking and self-monitoring that would have me as a member.º The therapist
rather than to self-monitor and to think about and the therapy are, by extension of working
actions. with the client, tainted.
Abuses of the Therapeutic Relationship 245
6.10.7.7.11 Limited energy In this way, the therapist is in the position of

power. The client becomes dependent, and
Depression is a major contributor to this
depending on the presenting problems, possibly
impediment. Individuals who are depressed will
needy. The client is vulnerable to abuse. This
often have vegetative signs that include lowered
abuse may take many forms from the more
energy. It then becomes difficult to cooperate in
subtle (i.e., the therapist starting therapy
therapy given that the major goal is to avoid any
sessions later than scheduled) through more
activity that requires action or energy. Levels of
moderate abuse (canceling therapy sessions) to
energy both within the session, for homework,
the severe abuse of physical or sexual aggression.
or for interpersonal relationships is minimal.
Sexual contact between a client and therapist will
invariably cause situations that manifest them-
6.10.7.7.12 Substance use selves as the client experiencing greater difficul-
If substance abusing clients come to therapy ties with trust, self-esteem, and problems
drunk or stoned, they cannot make use of the expressing anger (Simon, 1989). The clients
therapy. What may occur is state-dependent usually feel exploited, used, and confused
learning whereby they can only act in certain (Blackshaw & Patterson, 1992). Despite the
ways when under the influence of the substance. documented harmful effects of sexual involve-
Clients who are semiaware or semirelated to the ment with clients, 7±12% of therapists admit to
therapist will make little use of the therapy. having had sexual contact with a client (Gartrell,
When sober they either will not remember what Herman, Olarte, Feldstein, & Localio, 1986).
was said or done or will have distorted it due to The gender breakdown of the therapists was
the filter of the drugs. approximately 10% of male therapists and
2±3% of female therapists having engaged in
6.10.8 ABUSES OF THE THERAPEUTIC sexual activity with a client. Pope, Sonne, and
RELATIONSHIP Holroyd (1993) report that although the sexual
exploitation of a client is the most explicitly
Smith (1988) writes, ªThe practice of psy- defined ethical principle, it continues to be a
chotherapy involves much more than the mere problem within the mental health discipline.
application of psychological theory and tech- Other areas of potential problems occur in
niquesº (p. 59). The therapist±client relation- regard to fees and financial arrangements. The
ship is a unique establishment of a working Ethics Code for Psychology states that the
partnership with respect, trust, and confidenti- psychologist as early as possible define and
ality as its fundamental principles. This inter- make an agreement as to how the fee schedule is
actional process is the mechanism by which the arranged. Fees are consistent with laws, and are
effects of treatment are created and realized not misrepresented. Psychologists are permitted
(Smith, 1988). As with most interpersonal to use collection agencies (Canter, Bennett,
relationships, the psychotherapeutic process Jones, & Nagy, 1994).
has a frame or structure that delineates and With regard to therapy itself, psychologists
identifies the purpose and meaning of the are required to advise the client as early as
relationship. This frame consists of socially possible the structure and outline of therapy,
dictated components which serve as guidelines confidentiality and its limits, and the proposed
to how the therapeutic process should occur treatment plan. The psychologist is to provide
(Epstein, 1994). coverage in the event of their absence, and
Trust is an element of psychotherapy which is terminate the professional relationship in a
of primary importance. Clients expect that collaborative stance when it becomes evident
within reason, their needs are the focal concern that the client no longer requires the service or is
of the therapeutic relationship, and that the not benefiting from continued treatment (Can-
therapist's responses and interactions have the ter et al., 1994).
intention of promoting effective treatment gains In conclusion, therapists are bound by
(Galletly, 1993). The ethical dictum is that the clinical, ethical, and legal standards to maintain
therapist must act so as to avoid injury or harm the integrity of the psychotherapeutic process.
to the client. Epstein (1994) writes, ªIdeally, the therapist will
The client has been encouraged to suspend be able to fine-tune the frame into an empathic
their usual defenses, reveal deeply personal dynamic structure that is sensitive to the client's
thoughts and feelings, and ultimately become changing needsº (p. l7). The therapist is required
somewhat dependent upon the clinician. The to be not only competent in their chosen
client enters treatment with the expectation of profession, but respectful, conscious of, and
being helped. In addition, the client experiences adhere to ethical standards espoused by their
the development of intense feelings toward the colleagues, licensing boards, legal mandates,
therapist as a manifestation of the transference. and society as a whole in order to protect those
vulnerable to potential harm. Gorton and relationship. The client relies on the therapist
Samuel (1996) propose that comprehensive to provide treatment resulting in an asymme-
training and mandatory education on the topic trical or fiduciary relationship (Epstein, 1994).
of sexual and ethical issues be included as a
national requirement for graduate program 6.10.9 GENERAL GUIDELINES
accreditation.
The therapeutic work must take place within Sigmund Freud provided specific guidelines
a working partnership with respect, trust, and defining the ideal psychotherapeutic structure.
confidentiality as its fundamental principles. Cited in Epstein (1994), Freud stated that his
This interactional process is the mechanism by guidelines were imperative for creating and
which the effects of treatment are created and maintaining trust between therapist and client,
realized (Smith, 1988). Like every interpersonal and provided self-protection for the therapist.
relationship, the psychotherapeutic process has Freud advised that the client should receive
a frame or structure that delineates and informed consent explaining the nature of
identifies the purpose and meaning of the treatment. The therapist should practice absti-
relationship. This frame consists of socially nence and the nonexploitation of a client which
dictated components which serve as guidelines included not confusing transference for real or
to how the therapeutic process should occur true feelings or expressions toward the therapist
(Epstein, 1994). (Lakin, 1991). The therapist should maintain a
Trust is an element of psychotherapy which is neutral stance including not advocating any one
of primary importance. Clients expect that position or stance over another. The therapist
within reason, their needs are the focal concern should avoid dual agency or becoming involved
of the therapeutic relationship, and that the with a client already personally known to the
therapist's responses and interactions have the therapist. The therapist should practice relative
intention of promoting effective treatment gains anonymity and keep personal disclosures to a
(Galletly, 1993). The ethical dictum is that the minimum. Finally the therapist should collect
therapist must act so as to avoid injury or harm coherent and rational fees at regular intervals
to the client. (cited in Epstein, 1994). Recently, Simon (1992)
The client has been encouraged to suspend conceptualized treatment boundaries or frames
their usual defenses, reveal deeply personal necessary to maintain the integrity of treatment.
thoughts and feelings, and ultimately become These guidelines and principles mirror the
somewhat dependent upon the clinician. The ethical standards espoused by the American
client enters treatment with the expectation of Psychological Association (APA). The most
being helped. In addition, the development of recent published set of APA guidelines are the
intense feelings toward the therapist as a 1992 version (Canter et al., 1994). Simon advises
manifestation of transference occurs. In this that the therapist must follow the guidelines
way, the therapist, doctor, or psychologist is in below in order to create an effective ethical
the position of power, while the client assumes treatment process (Simon, 1992).
a more vulnerable position (Blackshaw & (i) Maintain therapist neutrality
Patterson, 1992). (ii) Encourage psychological separateness
In addition, legal duties mandated by courts between client and therapist
and statutes have further defined the psy- (iii) Maintain confidentiality
chotherapy relationship and the relevant and (iv) Secure informed consent for treatment
appropriate boundaries between the therapist (v) Encourage verbal interaction with client
and client. In sum, therapists are therefore (vi) Ensure that no current or future personal
accountable to professional, ethical, and legal relationship occurs with the client
standards (Simon, 1992). (vii) Minimize or avoid physical contact
The process of transference provides an (viii) Preserve anonymity of the therapist
avenue for either beneficial treatment to become (ix) Establish and maintain a consistent fee
actualized or noxious to the client by the policy
therapist exploiting the established trust. In (x) Provide a safe, consistent, and private
addition, countertransference, or feelings to- treatment setting
ward a client a therapist may have also become a (xi) Provide clear definition of time and
mode of either positive or negative influence to length of treatment sessions.
the therapeutic process (Smith, 1988). The
therapeutic relationship is described as fiduciary 6.10.10 APA CODE
in nature (Simon, 1992). A fiduciary relationship
exists when the client's compliance requires trust The 1992 Ethics Code of the APA clearly
and vulnerability while the therapist's position identifies general principles and ethical stan-
renders a clearly influential role upon the dards for all areas of psychological treatment.
APA Code 247
The creation of the first formal APA Ethics Psychologists must take reasonable steps and
Code was the result of the increasing profes- precautions to avoid harming their clients, and
sional activity of psychologists, both industrial to minimize harm when it is foreseeable and
and in mental health settings. As activity unavoidable. In this way, psychologists must be
increased, regulations and guidelines were able to recognize when their own personal
needed to ensure the integrity of treatment problems or conflicts may interfere with their
and the protection of all clients. The first Code effectiveness as a treating clinician. If a
was formulated from a critical incident method psychologist is aware that their personal
in 1948 which involved psychologists describing problems may be interfering with treatment,
what they felt was an ethical situation or they are obliged to seek assistance and
dilemma. The Ethics Committee of the APA determine if they need to suspend or terminate
then created a draft and final version of treatment. A psychologist must also not misuse
guidelines and standards in response to the their influence upon a client, especially as the
previously identified situations from the em- relationship between the therapist and client is
pirical data obtained from the critical incidents asymmetrical with the position of power lying
listed and defined by psychologists. The first with the therapist (Canter et al., 1994).
version was published in 1953, with subsequent The 1992 Ethics Code specifically prohibits
revisions in 1958, 1962, 1965, 1972, 1977, 1979, the psychologist and client engaging in any type
1981, 1989, and 1992 (Canter et al., 1994). of multiple relationship. A psychologist must
Following the outline of General Standards refrain from beginning a personal, scientific,
espoused by the APA Ethics Code, psycholo- professional, financial, or other relationship
gists are expected to provide services for which with a client as it may involve future harm or
they are competent based on their education exploitation of the client. The Code does,
and training. Continued training and education however, recognize that in some rural areas of
is required for the psychologist to remain in the country, situations in which clinicians who
touch with current and updated treatment know the client before treatment begins may not
methods and research outcomes. The psychol- always be avoided due to lack of resources.
ogist should speak with the client in a language Psychologists are also advised not to barter with
understood by the client to ensure that informed a client which means refraining from accepting
consent has occurred. In this way, the client is goods or services as a way of paying for
aware and cognizant of the proposed treatment psychological services. The psychologist may,
plan, procedures, or research (Canter et al., however, participate in bartering providing it
1994). does not cause the client harm, and does not
Psychologists need to be aware of how human involve any exploitation of the client (Canter
differences such as age, gender, race, sexual et al., 1994).
orientation, and disabilities can affect their Exploitation of the client is strictly forbidden
work and recognize when they may or may not in the Ethics Code. This includes not engaging
be qualified to treat any one particular in any sexual or personal relationship with
individual. If this occurs, the expectation exists students, supervisees, and clients (Canter et al.,
that the therapist will provide an appropriate 1994). Clear evidence exists that clients are
referral to a competent therapist with the harmed.
relevant expertise. Psychologists should always In conclusion, therapists are bound by
respect the rights of others to hold values, clinical, ethical, and legal standards to maintain
beliefs, or opinions different from their own. the integrity of the psychotherapeutic process.
Psychologists do not degrade those of differing Epstein (1994) writes, ªIdeally, the therapist will
religious values, cultural or ethnic backgrounds, be able to fine-tune the frame into an empathic
or politics. In this way, they are nondiscrimi- dynamic structure that is sensitive to the client's
native (Canter et al., 1994). changing needsº (p. l7). This is essential,
Psychologists are prohibited from engaging particularly since the therapeutic relationship
in any form of sexual harassment, defined by plays such an important part as an agent in the
sexual solicitation, physical advances, or verbal change process.
or nonverbal conduct that is sexual in nature
that occurs in the therapeutic encounter. If a
client has complained of being sexually har-
assed, the psychologist does not make pre- ACKNOWLEDGMENT
judicial decisions in response to the client being
a complainant, for example, denying admission The authors wish to acknowledge Gina
to a graduate program. Additionally, psychol- Fusco, a doctoral student in clinical psychology
ogists are prohibited from harassing or demean- at the Philadelphia College of Osteopathic
ing clients in any form (Canter et al., 1994). Medicine, for her assistance with this chapter.
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6.11
Treatment Maintenance and
Relapse Prevention
JOHN W. LUDGATE
Bristol Regional Medical Center, Bristol, TN, USA
6.11.1 OVERVIEW 251

6.11.2 DEFINITIONS OF RELAPSE AND RECURRENCE 252
6.11.3 REVIEW OF RELAPSE RATES AND PREDICTORS OF RELAPSE 252
6.11.3.1 Depression 252
6.11.3.2 Anxiety Disorders 253
6.11.3.3 Substance Abuse 255
6.11.3.4 Eating Disorders 255
6.11.3.5 Overall Review of the Extent of the Problem of Relapse 256
6.11.3.6 Review of the Predictors of Relapse 256
6.11.3.7 Treatment Implications that Follow from Research on Predictors of Relapse 256
6.11.4 MODELS OF RELAPSE 257
6.11.4.1 The Medical Biological Model 257
6.11.4.2 Cognitive Behavioral Models 257
6.11.4.2.1 Marlatt and Gordon's model 257
6.11.4.2.2 Shiffman's model 258
6.11.4.2.3 Teasdale et al.'s model 258
6.11.5 CLINICAL STRATEGIES TO REDUCE RELAPSE RISK 258
6.11.5.1 General Overview of Relapse Prevention Strategies 258
6.11.5.2 Application of Specific Relapse Prevention Procedures at Different Points in Therapy 259
6.11.5.2.1 Assessing the risk of relapse 259
6.11.5.2.2 Early therapy activities 259
6.11.5.2.3 Throughout therapy strategies 259
6.11.5.2.4 Pretermination procedures 260
6.11.5.2.5 Follow-up and aftercare activities 260
6.11.5.3 Working with the Patient who has Relapsed 261
6.11.6 CURRENT STATUS AND FUTURE DIRECTIONS FOR RELAPSE PREVENTION 261
6.11.1 OVERVIEW 1970s there has been an upsurge of interest in the

long-term effects of psychological treatments
In the psychotherapy literature the main and how treatment effects can be maximized and
source of attrition in psychotherapy has been maintained. As will be demonstrated in this
seen as dropouts during the acute phase of chapter there is still a considerable relapse rate
therapy. Rather less attention has been given to associated with all treatments of psychological
the problem of relapse and recurrence following disorders including psychotherapy and pharma-
sucessful treatment. However, since the late cotherapy. Cognitive therapy (Beck, Rush,
251
252 Treatment Maintenance and Relapse Prevention
Shaw, & Emery, 1979), behavior therapy (Wolpe recovery is said to occur when the number and
& Lazurus, 1966) and interpersonal psycother- severity of symptoms falls below the threshold
apy (Klerman, Weissman, Rounsaville, & used for defining onset for a specified period of
Chevron, 1984) have all demonstrated some time (Keller, Shapiro, Lavori, & Wolfe, 1982).
degree of efficacy in the acute treatment phase Defining relapse can also be problematic.
and also seem to have some preliminary promise Brownell, Marlatt, Lichenstein, and Wilson
in reducing relapse in certain clinical popula- (1986) have noted two different dictionary
tions. However, the task of further reducing the definitions of the term ªrelapse.º The first
still high relapse rates found in several disorders refers to an outcome and defines relapse as ªthe
such as depression (Belsher & Costello, 1988) recurrence of symptoms of disease after a period
and substance abuse (Hunt, Barnett, & Branch, of improvement,º and the second refers to a
1971) needs to be given serious attention by process, namely, ªthe act of backsliding,
clinicians and researchers. In this chapter the worsening, or subsiding.º The outcome defini-
relapse rates and predictors of relapse in a tion, often associated with biological or medical
number of disorders will be reviewed, and the models, has very different implications from the
implications of this research for clinical practice process definition, which suggests that relapse
will be outlined. A number of models of relapse involves a number of stages and is not a single
that can guide reseach and clinical practice will event (Marlatt & Gordon, 1985).
be described. Attention will be given to the Studies on long-term outcome in treatment
assessment of relapse risk and to planning often do not clearly specify the criteria used to
treatment in a manner designed to reduce the define relapse. Also, since different studies do
risk of relapse. Relapse prevention and main- not utilize standardized criteria for recovery,
tenance facilitating strategies will be outlined. relapse, and recurrence, comparing studies is
Some concluding comments on the present difficult. Wilson (1992a) points out that there
status of maintenance and relapse prevention are many problems inherent in attempting to
therapy procedures will be offered and future draw conclusions about relapse in psychological
directions for research and clinical practice in disorders due to the difficulty in drawing
this area will be suggested. distinctions between lapse, relapse, and recur-
rence and clarifying the usage and measurement
of these concepts in different disorders. Other
6.11.2 DEFINITIONS OF RELAPSE AND methodological problems with the studies
RECURRENCE conducted in this field include inadequate cell
size, differential attrition, failure to include
It is important to clearly define the terms control or comparison groups, and insufficient
ªrelapseº and ªrecurrenceº as these are often duration of follow-up.
used interchangeably. In the field of depression,
Klerman (1978) has suggested that clinicians
and researchers adopt the convention that the 6.11.3 REVIEW OF RELAPSE RATES AND
term ªrelapseº be used to refer to a return of PREDICTORS OF RELAPSE
symptoms within six to nine months after the 6.11.3.1 Depression
onset of the index episode and that the term
ªrecurrenceº be used to denote a return of A great deal of research has been conducted
symptoms after a period of six or twelve months into the long-term outcome of depressive
of remaining symptom-free. Klerman suggests disorders (see also Chapters 3 and 16, this
that relapse may refer to continuity or re- volume). The NIMH consensus panel (NIMH,
emergence of symptoms of the original episode, 1985) concluded that as many as 50% of patients
while recurrence would be considered a new with recurrent unipolar depressive disorder who
episode. Despite these guidelines there is still recover from an episode of depression will have a
considerable confusion regarding this distinc- recurrence within two years. Other reviewers in
tion in the literature. this field (Belsher & Costello, 1988; Lavori,
Distinguishing between a chronic continuity Keller, & Klerman, 1984) confirm these findings
of symptoms or behavior and a relapse following and additionally report a 20% relapse rate
recovery or remission has been problematic in within two months and a 40% rate within a year.
this field and made it difficult to establish Approximately 70% of unipolar depressed
accurate figures on relapse and recurrence. patients respond to antidepressant medication
Designating patients as relapsed presupposes in the short term but there is a considerable
that they have experienced a recovery or relapse rate with short-term pharmacotherapy
remission from the original index episode. (Ludgate, 1991). There is now an emerging body
Recovery can be defined in a number of different of evidence demonstrating that the use of
ways. In the field of depression, for example, maintenance medication (antidepressants or
Review of Relapse Rates and Predictors of Relapse 253
lithium) reduces the probability of relapse. Prien 1986; Evans et al, 1992), cognitive therapy still
and Kupfer (1986) concluded in a review of this fared better in terms of relapse rates although
field that the risk of relapse was approximately the use of maintenance medication also resulted
20% in patients continuing to take lithium or in relatively low rates of relapse. Wilson (1992b)
antidepressant medication compared to 50% concludes that cognitive therapy is at least as
who were switched to a placebo. Thase (1990) effective as maintenance medication properly
suggests that maintenance pharmacotherapy maintained for one year. In all of the studies
reduces the risk of recurrence over a two to carried out on the long-term outcome of
three year period from 80% to 50%. cognitive therapy for depression, no explicit
Behavioral approaches have shown some relapse prevention or maintenance procedures
promise in producing positive long-term out- are described. The therapy administered follows
come and reducing relapse in depressed patients that described by Beck et al. (1979) and focuses
(Gonzales, Lewinsohn, & Clarke, 1985; on providing cognitive and behavioral strategies
Thompson & Gallagher, 1984). Social skills that aim to alleviate depressive symptomatol-
training has been found to be superior to both ogy with the addition in some studies of booster
psychotherapy and tricyclic maintenance med- sessions and some additional therapy (Black-
ication at six month follow-up (Hersen, Bellack, burn et al., 1986). Only one study (Berlin, 1985)
Himmelhoch, & Thase, 1984). Behavioral used an explicit relapse prevention focus and
therapy was found to have a better course than attempted to determine its effects. Self-critical
pharmacotherapy, relaxation therapy, and patients were randomly assigned to standard
nondirective therapy in a two and a half year cognitive behavior therapy or to a specifically
follow-up of depressed outpatients (McLean & designed relapse prevention program. Both
Hakistian, 1990). treatments were equivalent in their effects on
Encouraging results have also been found maintenance of treatment effects (reduced
using interpersonal psychotherapy with de- depression and increased self-esteem) at six-
pressed patients (Weissman, 1994). Weisman, month follow-up.
Klerman, Pruscoff, Shalomskas, and Padian Despite lower relapse rates in depressed
(1981) found no difference between interperso- patients treated with maintenance pharma-
nal psychotherapy and antidepressant medica- cotherapy, cognitive therapy and interpersonal
tion at one year follow-up. Frank et al. (1990) psychotherapy compared to other treatment
used continuation interpersonal psychotherapy methods, relapse is still a significant problem in
(on a monthly basis for 20 weeks) and this area.
antidepressant medication as a continuation Wilson (1992b) suggests that the following
treatment for unipolar depressed patients variables appear to put depressed individuals at
initially successfully treated with either inter- greatest risk for relapse: chronicity, number of
personal psychotherapy or medication. They previous episodes, being in an environment of
found that maintenance medication had sig- high expressed emotion or where a high number
nificant prophylactic effects and interpersonal of critical comments are made by a spouse
psychotherapy had modest effects in reducing (Hooley & Teasdale, 1989), adverse life events,
relapse risk. residual depression after treatment, posttherapy
A number of reviews (Hollon, Shelton, & dysfunctional cognitive style (including the
Loosen, 1991; Ludgate, 1995; Wilson, 1992) presence of dysfunctional attitudes and a
have concluded that cognitive behavioral negative attributional style), low self-efficacy
therapy has a prophylactic effect in the concerning control over negative thoughts,
treatment of depression. It appears that patients dissatisfaction with major life areas, and
treated with short-term antidepressant medica- coexisting medical problems. Other predictors
tion have roughly twice the relapse risk for which there is at least some empirical
compared to patients receiving cognitive beha- support include endogenous subtype, duration
vioral therapy (22±38% vs. 65±78%). In the of index episode, the presence of an Axis II
NIMH study (Shea et al., 1992), cognitive disorder, higher levels of hopelessness at
therapy, interpersonal psychotherapy, and discharge, absence of social support, and
short-term Imipramine were compared. Relapse persistent neuroendocrine dysregulation after
rates at 18-month follow-up were: 36% for recover (Belsher & Costello, 1988; Lavori et al.,
cognitive therapy, 33% for interpersonal psy- 1984; Ludgate, 1994).
chotherapy, 50% for Imipramine, and 33% for
placebo. Return to treatment was significantly
lower in the cognitive therapy group than in the 6.11.3.2 Anxiety Disorders
other groups. In the only studies that compared
cognitive therapy to maintenance antidepres- While there has been a good deal of research
sant medication (Blackburn, Eunson, & Bishop, carried out on the short-term effects of a number
of therapies for anxiety disorders (see Chapters tenance activities include: reviewing changes
17±22, this volume), there are few studies that achieved and skills acquired during therapy,
provide outcome data on patients with anxiety continued practicing of skills, distinguishing a
disorders followed up for any significant period setback from a relapse, identifying high-risk
of time. Rappee (1991), reviewing research on situations for relapse, and coping with setbacks.
generalized anxiety disorders, concludes that the Results from three studies where agoraphobic
positive effects of psychological treatments tend panic and simple phobia patients completing
to endure over 6±12 month follow-up periods. In this maintenance program were evaluated at
a three-year follow-up of generalized anxiety 6±15 months, follow-up showed that overall,
disorder patients receiving short-term stress only 7% of patients relapsed and 10% needed
innoculation training (Meichenbaum, 1977), further treatment, which compares favorably
Holcomb (1986) found that these patients with the means of previously reported studies
required fewer hospital readmissions compared where 14% relapsed and 25% needed further
to patients receiving pharmacological treatment. treatment.
In agoraphobia, Telch, Tearnan, and Taylor A number of longer-term follow-up studies
(1983) found relapse rates of 27±50% in patients have been conducted in obsessive compulsive
treated with Imipramine alone. Zitrin, Klein, disorder treated with cognitive behavior ther-
and Woerner (1980) found that active psy- apy. Rates of relapse reported are consistently in
chotherapy methods such as exposure, when the 20±25% range in follow-up periods ranging
used in conjunction with Imipramine in the from seven months to three years (Foa et al.,
treatment of agoraphobia, reduces the relapse 1983). Similarly, relapse rates of 20±30% have
rate to 19% vs. 31% with Impipramine alone been reported over follow-up periods of up to
over a two-year follow-up. Encouragingly, six years following treatment by exposure
Emmelkamp and Kuipers (1979) found that therapy with this population (Emmelkamp &
60±70% of agoraphobic patients who responded Kuipers, 1979).
to cognitive behavior therapy maintained their While follow-up studies examining relapse
improvement at four-year follow-up. In treating and maintenance of treatment effects in patients
panic disorder, medications such as Alprozolam with anxiety disorders are somewhat limited, the
and Imipramine have been found to be very literature suggests that patients treated with
effective at eliminating panic attacks in the short cognitive behavior therapy have a lower risk of
term but relapse rates of 70±90% following relapse compared to other treatment methods.
discontinuation have been found with Alpro- However, as in the case of depression, a
zolam and 35±40% with Imipramine (Brown & significant proportion of patients do not
Barlow, 1992). A series of studies on cognitive maintain treatment gains and experience a
therapy with panic disorder patients (Beck, recurrence. There are few well-controlled stu-
Sokol, Clark, Berchick, & Wright, 1992; Clark et dies that investigate predictors of maintenance
al., 1994; Craske, Brown, & Barlow, 1991; Ost & and relapse following treatment for anxiety
Westling, 1995) show impressively low relapse disorders. However, certain clinical character-
rates ranging from 0 to 19% in patients treated istics have been implicated in poorer longer-
with cognitive behavior therapy whose panic term outcome. These include a comorbid
attacks resumed in the follow-up period. In a diagnosis of a personality disorder (Turner,
review of behavioral treatments of agoraphobia, 1987), concurrent depression (Brown & Barlow,
simple phobia and obsessive compulsive dis- 1992), negative life events (Munroe & Wade,
order with a follow-up period of at least one 1988), and interpersonal stressors and health
year, Ost (1989) reports relapse rates of 24% for problems (Tearnan, Telch, & Keefe, 1984)
agoraphobia, 4% for simple phobia, and 15% Rappee (1991) has hypothesized that informa-
for obsessive compulsive disorder. Ost con- tion processing deficits are implicated in the
cludes that: further improvement after treat- long-term maintenance of generalized anxiety
ment is moderate in agoraphobia and obsessive disorder. In the case of panic disorder, a
compulsive disorder and nonexistent in simple cognitive factor, that is, misinterpretation of
phobia, overall about one-fifth of these patients body sensations, is hypothesized to be involved
relapse, and a large proportion seek further in the etiology and maintenance of panic attacks
treatment. Ost (1989) describes a cost-effective (Clark et al., 1988), and this hypothesis has been
maintenance program for anxiety disorders given support in two studies which showed that
following initial behavioral treatment which is higher scores on the Body Sensations Inter-
introduced in the last session of treatment when pretation Questionnaire (Clark et al. 1988), an
a contract to implement maintenance activities instrument which measures the tendency to
is signed by the patient. Over a six-week period misattribute sensations, were predictive of
following termination, the patient and therapist relapse at 15-month follow-up in panic patients
have 1.5±2 hours of telephone contact. Main- who were panic-free at termination (Clark et al.,
Review of Relapse Rates and Predictors of Relapse 255
1988; Westling & Ost, 1995). In the area of gambling, and overeating, it was found that the
obsessive compulsive disorder, Emmelkamp following three factors accounted for over 70%
and colleagues (Emmelkamp, Kloek, & Blaauw of relapses: negative emotional states (e.g.
1992) have empirically demonstrated that life frustration, anger, anxiety, depression, and
events, inadequate coping style, and high boredom): social pressure; and interpersonal
expressed emotion environments are predictive conflict (Cummings, Gordon, & Marlatt, 1980).
of relapse. In conclusion, though little systema- In reviewing this area, Marlatt and Gordon
tic research has been done in this area, the (1985) note that there has been condiderable
following factors appear to increase the risk of consistency found in studies examining predic-
relapse in anxiety disorders: comorbid depres- tors of relapse across various addictive beha-
sion or personality disorder, adverse life events, viors. They further state that these three factors
dysfunctional cognitive style after treatment, (negative emotional states, social pressure, and
deficient coping skills, and a high expressed interpersonal conflict) appear to be the most
emotion environment. frequently found high-risk situations for relapse
in addictive disorders with urges and tempta-
tions, negative physical states, testing personal
6.11.3.3 Substance Abuse control, and positive emotional states being
implicated in a somewhat smaller number of
The treatment of substance abuse has relapse situations.
become increasingly more research-driven in
recent years (see Chapter 25, this volume).
Stimulated by the seminal work of Marlatt and 6.11.3.4 Eating Disorders
colleague (Marlatt & Gordon, 1985), a good
deal of research on relapse in addictive Psychological treatments for eating disorders
behaviors has been carried out. In this field, have grown in range and sophistication in recent
rates of relapse are disturbingly high across the years (see Chapter 29, this volume). A good deal
spectrum of addictive behaviors (Marlatt & of attention is now being given to long-term
Gordon, 1985). Additionally, the temporal outcome in eating disorders although, as
course of the relapse process is remarkably Orimoto and Vitousek (1992) note, these studies
consistent across the various disorders. In a often track the status of diagnosed individuals
comprehensive review of a large number of over various time periods following diverse and
treatment studies that followed successfully often poorly specified forms of treatment, which
treated addictive behavior patients over a 12- makes comparison of findings across studies
month follow-up, Hunt et al. (1971) plotted difficult. A review of the literature on anorexia
survival rates for a number of addictive nervosa suggests that a good long-term out-
disorders and concluded that: the vast majority come is attained by roughly 40%, with 11±33%
(65±75%) of treatment successes relapse within in an intermediate category and 14±42% judged
12 months, two out of three relapses occur to be doing poorly (Orimoto & Vitousek, 1992).
within three months, relapse rates seem to Relapse rates following treatment are hard to
stabilize and plateau over time (after six estimate since a great number of anorexic
months), and relapse rates and time to relapse patients do not attain recovery or remission
are simular for heroin, nicotine, and alcohol after treatment and cannot thus be candidates
addictions. Marlatt and Gordon (1985) confirm for relapse by definition. Orimoto and Vitousek
the finding that approximately two-thirds of all conclude that only roughly 50% of anorexics
relapses across addictive disorders occur within will eventually attain normal weight and
90 days of initiation of a treatment program or menstruation and a significant subgroup will
attempts at cessation. The high rate of relapse experience a relapse in the future, with the exact
in addictive disorders is exemplified by research percentage of actual relapses being hard to
on smoking where as many as 88% of treated ascertain.
patients will relapse over a two-year period with Bulimia nervosa is a relatively recent diag-
the majority of relapses occurring within seven nosis and the long-term course of the disorder is
months with some stabilization of rates after 15 still being investigated. However, some tentative
months (Brandon, Tiffany, Obremski, & Baker, conclusions can be drawn from the literature.
1990). Approximately 53% of patients improve over
Marlatt and his colleagues (Marlatt & 12±15 months without formal therapy (Mitch-
Gordon, 1985) have carried out extensive ell, Davis, & Goff, 1985). However, only one-
research into the predictors of relapse in third of a large sample of treated and untreated
addictive disorders. Based on an analysis of patients remained abstinent from bulimic
311 relapse episodes obtained from patients with behavior over a one-year period (Mitchell,
problems in the areas of smoking, drinking, Davis, Goff, & Pyle, 1986). In addition Mitchell
et al. (1986) found that as many as one-third of problem (up to 50% over two years) in
relapses take place within one month of depression. High rates of relapse (of the order
treatment. Keller, Herzog, Lavori, and Brad- of 60±80%) and a short survival time (the
burn (1992) found that one-third of bulimics majority of relapses occurring within three
remained in the index episode three years later months) are consistently found in addictive
and there was a cumulative probability of disorders. Rather less is known about long-term
relapse of 63% over a follow-up of 35±42 outcome in the fields of anxiety and eating
months. Orimoto and Vitousek (1992) summar- disorders, and so no firm conclusions can be
ize the cognitive behavior therapy outcome drawn. However, clinical experience would
studies carried out in this area and show a suggest that relapse and recurrence are sig-
median figure for abstinence from binging and nificant problems in these disorders too. There
from purging of 61% and 45.5%, respectively, is a considerable economic cost involved in the
at follow-ups of three months and longer. They still high rate of recurrence in psychological
also suggest, based on some preliminary find- disorders. The human cost is also very high in
ings, that interpersonal psychotherapy may terms of distress and demoralization for the
show some promise in preventing relapse and relapsing patients, their families, and for the
maintaining treatment gains. Few studies using clinicians who treat them.
cognitive behavioral methods have used treat-
ment formats that use explicit relapse preven-
tion procedures, and this is an area for further 6.11.3.6 Review of the Predictors of Relapse
investigation following the promise of initial
The prediction of relapse has a number of
studies in this area (Fairburn, Kirk, O'Connor,
important consequences. First, it assists in our
& Cooper, 1986; Wilson, Rossiter, Kleifield, &
understanding of the fundamental processes
Lindholm, 1986).
responsible for change during and after treat-
In the field of eating disorder, there are few
ment and on the nature of relapse. At a more
systematic studies of predictors of long-term
practical level this work can help to identify
outcome following treatment. Keller et al.
individuals likely to show a poorer long-term
(1992) found that maintenance of recovery in
response to treatment. This can help in treat-
bulimia nervosa could be predicted by less
ment planning. Insofar as the predictors
disturbed eating behaviors, more positive self-
established are potentially modifiable (e.g.,
body image at intake, and having good friends.
personal variables, such as dysfunctional beliefs
Mitchell et al. (1985) found that the antecedent
or a poor sense of self-efficacy), these can
conditions for relapse included coping with
become the focus of therapy in an attempt to
stressful situations (80%), feeling anxious or
prevent relapse.
nervous (23%), and feeling depressed (23%).
Across the disorders reviewed there appear to
Root (1990) showed that triggers to relapse in
be some common factors that put individuals at
bulimic patients were found to include inability
risk for relapse. These include negative life
to cope with feelings, attitudes that give rise to
events, inability to cope with stress or negative
negative affect, and stressful events. Freeman,
affect, persistence of certain cognitive patterns
Beach, Davis, and Solyom (1985) found that
or dysfunctional beliefs, and a low sense of self-
body image dissatisfaction at the end of
efficacy. It could be postulated that the above
therapy was found to be the most powerful
risk factors may also predispose patients to
predictor of subsequent relapse. Cognitive
relapse in other psychological disorders that are
states such as guilt and the tendency to make
beyond the scope of this review.
internal, global, and uncontrollable causal
attributions for an initial binging have been
found to be predictors of subsequent binge 6.11.3.7 Treatment Implications that Follow
behavior (Grillo & Shiffman, 1994). from Research on Predictors of Relapse
Research and clinical experience on relapse
6.11.3.5 Overall Review of the Extent of the and its prediction suggest a number of rules of
Problem of Relapse clinical practice, which if observed may lower
the risk of relapse in patients with psychological
Relapse rates following treatment have been disorders (Ludgate, 1995). The following stra-
well-established for depression. The incidence tegies may be expected to facilitate maintenance
of relapse in depression has been shown to be and prevent relapse:
reduced by the use of maintenance medication (i) cognitive distortions, dysfunctional as-
and psychosocial treatments such as cognitive sumptions, and other personal variables that
behavior therapy and interpersonal therapy. can create a vulnerability to relapse should be
Nevertheless, relapse still remains a significant dealt with prior to termination of therapy;
Models of Relapse 257
(ii) residual symptoms of emotional disor- that they have no control over the relapse
der, even those at mild or subclinical levels, process, which may result in a further down-
should be targeted therapeutically prior to ward spiral of negative cognition, helplessness,
discharge; and symptom recurrence (Marlatt & Gordon,
(iii) patients who evidence high symptom 1985; Wilson, 1992).
levels and a maladaptive cognitive style post-
treatment should be kept in treatment longer
and maintenance therapy provided; 6.11.4.2 Cognitive Behavioral Models
(iv) comorbid Axis I or Axis II disorders
6.11.4.2.1 Marlatt and Gordon's model
should also be addressed in treatment;
(v) general problem-solving and self- Marlatt and Gordon's (1985) model of the
management skills with wide application should relapse process in addictive disorders has had a
be practiced regularly during therapy, and a major impact in the field of relapse prevention
sense of self-efficacy should be fostered; since the late 1980s. Marlatt and Gordon
(vi) future life stressors should be anticipated postulate that newly abstinent patients experi-
and planned for where possible; ence a sense of perceived control up to the point
(vii) significant others should be involved in at which they encounter a high-risk situation,
treatment, and therapy should focus on lifestyle which most commonly entails a negative emo-
modification, both of which may help to tional state, an interpersonal conflict, or an
reinforce changes made in treatment. experience of social pressure. If individuals cope
effectively in the high-risk situation, perceived
control and self-efficacy increase, which in turn
6.11.4 MODELS OF RELAPSE makes the probability of relapse decrease.
Conversely, the hypothesized result of a failure
The importance of deriving treatment and
to cope with a high-risk situation is a decrease in
relapse prevention methods from a coherent
a sense of self-efficacy, which in turn increases
model has been stressed in several reviews in this
the probability of relapse. Each experience of
field (Ludgate, 1995, Teasdale, Segal & Wil-
successful or unsuccessful coping with a high-
liams, 1995; Wilson, 1992a). A conceptualiza-
risk situation builds up a greater or lesser sense of
tion of relapse benefits not only theoretical and
self-efficacy, which determines the future risk of
research developments in this field but, most
relapse in similar circumstances. Marlatt and
importantly, can guide clinical practice and
Gordon (1985) contend that individuals' reac-
assist in the development of rationally derived
tions to the initial slip and their attributions
relapse prevention procedures. Finally, a co-
regarding the cause of the slip are the determin-
herent explanation of relapse can assist relapsed
ing factors in the escalation of a lapse or setback
patients in making sense of this often baffling
into a full-blown relapse. The transition from
and mysterious process and, as a result, help
slip or lapse to relapse involves the ªabstinence
generate both hope and a sense of control.
violation effect,º which results from a state of
cognitive dissonance regarding the nonabstinent
6.11.4.1 The Medical Biological Model behavior and the individual's image of being
abstinent. This dissonance can be reduced by
Until recently the predominant model of either changing the behavior or changing the
relapse was the medical biological view which image, and characteristically in this population
stressed physiological or biochemical events is resolved by the latter. Internal and stable
that led to a return of symptoms or behaviors attributes for the slip also lead to further lapse
characteristic of the syndrome. This is seen in behavior. This model has received a good deal of
the definition of relapse as ªthe recurrence of a empirical support and has the merit of disman-
disease after a period of improvement.º In the tling the process of relapse and exploring
extreme version of this model (the disease subjective and cognitive variables in a manner
model), a relapse into addictive behavior or into that has important treatment implications.
depression is an event over which the individual Marlatt and Gordon (1985) argue that
has little control as it is assumed that it is relapse prevention and maintenance should
precipitated by physiological or biochemical focus on teaching individuals who are trying
changes that lead invariably to symptom re- to change their behavior how to anticipate and
emergence or behavioral loss of control. cope with the problem of relapse. Relapse
This model has been criticized on a number of prevention therapy should include: identifica-
grounds including the charge that it ignores tion and preparation for high-risk situations;
known psychological factors in relapse and coping with negative emotional states, inter-
induces a sense of hopelessness and helplessness personal conflict, and social pressure; training
in relapsed patients, stemming from the belief in general coping or self-management skills; slip
recovery and relapse-crisis debriefing; pro- depression and also the mechanisms by which
grammed relapse and relapse rehearsal; lifestyle cognitive therapy achieves its prophylactic
interventions; and education about the disorder effects in the treatment of depression. This
and relapse. The use of Marlatt and Gordon's model involves an information-processing ana-
model in disorders outside the area of addictions lysis of depressive relapse. It hypothesizes that
has been advocated. Wilson (1992b) examines following recovery, mild states of depression
the possible role of this model in efforts to deal can reactivate depressogenic cycles of cognitive
with depressive relapse. In particular he stresses processing similar to those found during a major
the need to enhance depressed patients' sense of depressive episode. Teasdale et al. suggest that
self-efficacy, and suggests strategies to foster preventive interventions such as cognitive
this. Emmelkamp et al. (1992) have adapted this therapy operate by changing the patterns of
model in arriving at a cognitive behavioral cognitive processing that become active in states
model of relapse in obsessive compulsive of mild negative affect preceding a full relapse
disorder. Ludgate (1994) describes how many into major depression. They suggest that the
of the strategies described by Marlatt and redeployment of attention utilized in stress-
Gordon are also applicable at various stages in reduction procedures based on the techniques of
the therapy of emotionally distressed patients. mindfulness meditation (Kabat-Zinn, 1990) can
be integrated with cognitive therapy procedures
into a system of attentional control training.
6.11.4.2.2 Shiffman's model This approach would be applicable to recovered
depressed patients and would serve as a means
Shiffman (1989) argues that the risk of relapse
of preventing relapse. Teasdale and colleagues
is related to the operation of three mechanisms:
provide a description of this training which
enduring personal characteristics (e.g., coping
teaches generic psychological, self-control skills
style and individual vulnerability factors such as
and can be used on a continuing basis to
low self-esteem); background variables (e.g., life
maintain skills after initial training. While no
events, relationship issues, mood, motivation);
data on the effectiveness of this approach in
and precipitants (e.g., thoughts, feelings, and
preventing relapse exist to date, this appears to
events that can lead to a relapse). Background
be a useful and stimulating conceptualization of
and precipitating factors can both be viewed as
relapse and relapse prevention that deserves
high-risk situations. Background factors serve
further attention.
to ªset the stageº for relapse and may reach a
threshold level where relapse becomes more
likely. How individuals react to these high-risk
situations will influence where their level of 6.11.5 CLINICAL STRATEGIES TO
relapse proneness crosses the threshold for REDUCE RELAPSE RISK
relapse. The individuals' reactions to these
situations will be determined by their coping 6.11.5.1 General Overview of Relapse
skills, their sense of self-efficacy, and their Prevention Strategies
expectancies regarding outcome and the effect
Maintenance and relapse prevention depend
of using their problem-solving skills. This model
on the nature and natural course of the specific
is useful in introducing the valuable concept of
disorder involved, and the specific procedures
relapse proneness and the notion of factors from
selected to target relapse prevention and
different domains mutually interacting, with a
maintenance in therapy also need to be linked
threshold for relapse being established by
to a detailed case conceptualization for each
background variables. The treatment implica-
patient (Persons, 1989). However, there are a
tions of this model are: first, background factors
number of strategies which might be expected to
need to be identified, monitored, and modified
facilitate maintenance and prevent relapse
in order to keep relapse proneness below a
across the various psychological disorders
threshold level; second, enduring personal
(Greenwald, 1988; Krantz, Hill, Foster-
characteristics need to be worked on to reduce
Rawlings, & Zeeve 1984; Ludgate, 1995;
vulnerability to relapse; and third, precipitants
Marlatt & Gordon 1985; Miller, 1984; Shiff-
need to be anticipated and planned for where
man, 1989). These strategies include:
possible.
(i) increasing patient responsibility within
sessions and ensuring more between-session
activities as therapy proceeds;
6.11.4.2.3 Teasdale et al.'s model
(ii) promoting internal attributions of
Teasdale and colleagues (1995) have pro- change;
posed a model of depressive relapse which (iii) getting the patient to practice beyond a
attempts to explain the process of relapse in criterion (overlearning);
Clinical Strategies to Reduce Relapse Risk 259
(iv) working on a variety of targets and moderate risk (where several of these factors are
providing training in general problem-solving in evidence), or low risk (where none of these
or self-management skills; factors are in evidence). The focus of therapy
(v) developing a self-therapy program for use and the choice of treatment strategies can then
after formal therapy ends; be devised in the light of the assessment of
(vi) helping patients anticipate high-risk sit- relapse risk. This risk analysis also allows the
uations and develop an emergency plan to deal therapist to make decisions regarding aftercare.
with setbacks; Patients at high risk can be offered continuation
(vii) education regarding relapse, developing therapy and, if possible, engage in active
realistic expectations, and working on cogni- therapy even after symptom remission to work
tions regarding possible lapses or setbacks; on relapse prevention and maintenance. Pa-
(viii) assisting patients in recognizing early tients at moderate risk may be offered booster
warning signs of possible relapse and interven- sessions while patients at low risk may have
ing quickly and appropriately when these occur; their last several therapy sessions spaced out
(ix) fading the frequency of sessions later in before discharge and be invited back for
therapy; occasional refresher sessions (Ludgate, 1992).
(x) using booster or refresher sessions after
acute therapy ends;
6.11.5.2.2 Early therapy activities
(xi) modifying the patient's lifestyle or en-
vironment to ensure reinforcement of changes In the early part of therapy the ªmental setº
made; necessary for eventual maintenance and relapse
(xii) involving significant others in treatment. prevention activities can be facilitated by
stressing that therapy will be time-limited and
that the goal is to provide methods that patients
6.11.5.2 Application of Specific Relapse can subsequently use to ªbecome their own
Prevention Procedures at Different therapist.º Eventual termination should be
Points in Therapy discussed and the therapist should emphasize
the importance of the maintenance and under-
6.11.5.2.1 Assessing the risk of relapse
score the notion that therapy involves learning
During the assessment phase and in the early self-control methods which patients can use on
stages of therapy, data should be collected to their own after therapy ends. The therapist
allow a comprehensive individual conceptuali- should also stress the importance of patients
zation which guides treatment planning being active in the therapy process, practicing
(Persons, 1989). As a part of an overall new skills, and setting agendas. This will help
comprehensive case conceptualization, a risk facilitate the shift later in therapy to patients
analysis can be carried out for each patient. This working on maintenance and relapse prevention
will include: an analysis of enduring personal on their own.
characteristics (e.g., coping style, dysfunctional
beliefs); background variables (e.g., life events,
6.11.5.2.3 Throughout therapy strategies
stressors); and possible precipitants to relapse
based on the patient's history (i.e., events, As an attempt to maximize the gains made in
thoughts, and feelings that could lead to a therapy, it is recommended (Ludgate, 1995) that
recurrence). In addition, the patient's sense of throughout therapy attention be paid to the
self-efficacy and their perception of their following:
resources or skills to deal with life problems (i) reviews of skills at regular intervals;
can be assessed at different points in therapy as (ii) self-monitoring of progress;
new information becomes available. In the case (iii) overpractice of skills (overlearning);
of depression, a risk-analysis might be based on (iv) teaching skills with wide application;
the following factors: number of prior episodes, (v) generalizing skills or tools;
duration of episode, comorbidity (especially (vi) working at the schema or belief level and
Axis II disorders), coexisting medical condi- dealing with Axis II issues and comorbid
tions, post-treatment symptom levels, vulner- diagnoses, where necessary;
ability factors (poor self-esteem, dependency), (vii) dealing with vulnerabilty issues;
dissatisfaction with life areas, post-treatment (viii) ensuring that the patient become more
cognitive characteristics (dysfunctional atti- and more active in therapy;
tudes, attributional style), sense of self-efficacy (ix) increasing the emphasis on between-
after treatment, social support, and life stres- session behavior;
sors. Individual patients can then be character- (x) fostering internal attributions for change;
ized as a result of this case analysis as high risk and
(if a significant number of these factors exist), (xi) working on reactions to setbacks.
6.11.5.2.4 Pretermination procedures in the content of these sessions. Continuation

therapy involves working actively on areas of
In the later stages of therapy it is often
vulnerability, anticipating high-risk situations,
beneficial to gradually taper off or space
and continuing to practice and overlearn skills.
therapy sessions. There are three important
Booster sessions are focused more on reviewing
therapeutic tasks to be accomplished prior to
progress and dealing with any residual pro-
termination which may help reduce the risk of
blems or current difficulties experienced by the
relapse. These are: first, developing a self-
patient. Although reviews of the effectiveness of
therapy or maintenance plan; second, reviewing
booster sessions have shown that the addition
skills learned in therapy and rehearsing the
of these follow-up sessions are only moderately
application of these to future high-risk situa-
successful in maintaining behavior change
tions; and third, learning to identify early
(Whisman, 1990), there are some obvious
warning signals of lapses or slips and developing
advantages clinically to using booster sessions
an ªemergency planº to cope with these
after the initial treatment has ended. Booster
setbacks. A good rationale for maintenance
sessions encourage patients to take more
activities needs to be given and thoughts and
responsibility in solving problems or managing
feelings related to continued self-therapy should
their dysfunctional behaviors or mood states
be identified and restructured if necessary at this
with the therapist's role becoming more that of
time. A list of possible helpful maintenance
a consultant or adviser. They also allow
activities can then be drawn up collaboratively
continuing monitoring of symptoms and ap-
with the patient. To introduce the procedure of
propriate intervention if necessary. Patients are
self-monitoring of early warning signals of
more likely to be accountable in terms of
relapse, the patient first needs to be socialized
maintenance activities if they know they will be
to the concept of relapse or recurrence as a
reporting back on their progress in booster
process, not an event, and hence to the
sessions. Whisman (1990) recommends that the
importance of early detection and intervention
natural relapse rate for the problem being
in the sequence. Using the patient's past history
treated be first determined, and maintenance
and the pattern of events in the most recent
sessions be scheduled during this high-risk
episode, it may be possible to come up with
period rather than arbitrarily scheduled. He
some key prodromal symptoms or behaviors
suggests that the effectiveness of booster
that signal the beginning of the relapse process.
sessions can be improved by including the
A regular monitoring system carried out by
following components: a review of skills
patients themselves or by the therapist can then
covered in therapy and problem-solving diffi-
be set up to determine the presence of any of
culties encountered in their implementation;
these early warning signs. Finally, a specific
teaching new or familiar skills to deal with
ªemergency planº can be generated before
problems arising during the follow-up period;
therapy ends, which should contain steps that
reinforcing the individual's accomplishments
can be taken in the event of symptoms or
and positive achievements as well as anticipat-
maladaptive behaviors reaching certain levels. It
ing and planning for future stressors; encoura-
is also helpful at this point to discuss the criteria
ging individuals to involve themselves in
that will be used in making a decision to return
self-help or community social support systems;
to therapy or seek hospitalization.
and promoting lifestyle changes that are
incompatible with relapse. Group refresher
sessions may be an alternative to individual
6.11.5.2.5 Follow-up and aftercare activities
booster therapy sessions for patients who are
There are a number of options for the doing well and have a somewhat lower risk of
therapist in terms of aftercare activities. These relapse. As described by Ludgate (1992), this is a
include formal maintenance or continuation cost-effective way to promote maintenance in
therapy, booster sessions, and refresher ses- former patients who are invited to attend group
sions. These decisions should follow from an refresher workshops that review general strate-
analysis of the potential for relapse in each gies for solving problems, managing moods and
particular case. Maintenance or continuation stress, and changing behaviors. The emphasis is
therapy (Thase, 1990) is clearly the most on skills rather than specific patient issues and
intensive in terms of therapist time and effort these workshops focus on education and skill
and would usually be reserved for patients who consolidation rather than therapy per se. In
are symptomatically recovered but at high risk addition to being cost-effective in terms of the
for relapse. therapist's time, these workshops allow mon-
The essential difference between continuation itoring of former patients' progress, which can
therapy and booster sessions lies in the facilitate decisionmaking regarding the need for
frequency and duration of sessions and also further aftercare interventions.
Current Status and Future Directions for Relapse Prevention 261
6.11.5.3 Working with the Patient who has Studies are needed across all areas of
Relapsed psychological disorders that will employ more
standardized utilization of relapse prevention
The tasks facing the therapist in this situation strategies during and after therapy.
are: to conceptualize and help the patient The development of treatment protocols for
understand the relapse process, to re-instill a the continuation phase of therapy for patients at
sense of self-efficacy, and to collaborate with the high risk is also a priority in this field. Research
patient in generating a plan to recover from the into factors involved in the maintenance of
lapse or setback. The extent and duration of the treatment effects and in the prevention of
recurrence should be carefully explored in order relapse is an important goal for both researchers
to help distinguish a lapse from a full relapse. and clinicians. There are a number of research
The task of the therapist and patient is to questions that need to be answered by well-
interupt the relapse process. It is important to controlled studies. Wilson (1992a) argues that
explore patients' expectations regarding recov- studies with long-term follow-up periods (e.g.,
ery, relapse, and the course of their disorder. If three years or more) are needed, as few currently
these are unrealistic, the therapist may help exist and most studies are confined to periods of
patients to substitute more realistic expecta- 12 months or less. Research is also needed into
tions. The therapist should help the patient the mechanisms responsible for relapse, or
ªmake senseº of what happened in this relapse conversely for maintenance of initial remission.
episode, which will help to demystify the Clear predictions about conditions for relapse
recurrence, give a greater sense of control, arising out of well-formulated theoretical
and encourage hope that the situation can be models need to be made and empirically tested.
improved. The therapist should help foster Increasing our ability to predict the occurrence
external, unstable, and specific attributions of relapse in particular disorders can be
regarding the relapse. The therapist can review considered a high-priority task as it has obvious
with the patient strategies used during this clinical implications in terms of treatment
episode and what impact they had. By a process planning for at-risk individuals. Research into
of guided discovery the patient can identify the development of valid and reliable measures
skills learned in therapy that could be applied to of relapse risk is also an important research and
this situation. A list of options can be drawn up clinical task at this time. Long-term outcome
to deal with the setback. It is important that the needs to be investigated in well-controlled
patient be as active as possible in the task of studies which include clearly defined relapse
generating the remedial plan as this offsets prevention strategies applied in either the acute
hopelessness and increases the sense of self- phase of treatment or during a continuation or
control. Finally, patients can be encouraged to maintenance phase of therapy following initial
consider what has been learned from this recovery. More research into the efficacy of
experience and what they would do differently booster sessions is needed and, in particular,
if faced with a similar situation in the future. into the optimal timing of booster sessions after
treatment. Knowledge of survival time for a
particular disorder may help to identify parti-
6.11.6 CURRENT STATUS AND FUTURE cular points in time for certain disorders when
DIRECTIONS FOR RELAPSE relapse is most likely and when booster sessions
PREVENTION could usefully be scheduled. Wilson (1992a)
advocates that several different types of relapse
Since the late 1980s considerable progress has prevention procedures such as maintenance
been made in the area of predicting relapse and strategies integrated into the initial treatment
in relapse prevention. While there have been program, boosters sessions and post-therapy,
appreciable advances in producing models of and minimal-contact procedures (self-help
relapse and therapeutic methods to prevent groups, telephone contact, bibliotherapy) be
relapse in addictions (Gossup, 1989; Marlatt & compared in terms of efficacy. To date, the
Gordon, 1985; Shiffman, 1989) and sexual shotgun or ªmore is betterº approach appears
deviancy (Laws, 1989), there is a need for to be the norm and research is needed on the
clinical guidelines for relapse prevention in contribution made by the different components
other fields such as depression, anxiety, and of relapse prevention programs (e.g., anticipa-
eating disorders. Some practical suggestions tion and planning for high-risk situations, early
have been offered in the literature (Greenwald, detection of warning signals of relapse, pro-
1988; Ludgate, 1994; Miller, 1984), but there are grammed relapse, relapse rehearsal, self-efficacy
few specific guidelines for working with in- training, lifestyle modification, and interven-
dividuals with these disorders to promote tions for vulnerability issues). Studies that
maintenance and reduce the risk of relapse. investigate predictors of relapse and sustained
improvement, particularly therapy and patient for bulimia nervosa. Behaviour Research and Therapy,
factors that are amenable to change, are needed 24, 629±643.
Foa, E. B., Grayson, J. B., Steketee, G., Doppelt, H. C.,
to inform clinical practice. Turner, R. M., & Lattimer, P. L. (1983). Success and
Pursuing some of the suggestions outlined failure in the behavioral treatment of obsessive-compul-
above would serve to further expand some of the sives. Journal of Consulting and Clinical Psychology, 15,
recent exciting developments in this crucially 287±297.
Frank, E., Kupfer, D. J., Perrel, J. M., Cornes, C., Jarrett,
important field of maintenance of treatment D. B., Mallinger, A. G., Thase, M., McEachran, A. B., &
effects and prevention of relapse. Grochocinski, V. J. (1990). Three year outcomes for
maintenance therapies in recurrent depression. Archives
of General Psychiatry, 47, 1093±1099.
Freeman, R. J., Beach, B., Davis, R., & Solyom, L. (1985).
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Cognitive therapy for depression. New York: Guilford Gonzales, L. R., Lewinsohn, P. M., & Clarke, G. N. (1985).
Press. A longitudinal follow up of unipolar depressives: An
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Work Research and Abstracts, 21(1), 21±33. investigation of the abstinence violation effect in binge
Blackburn, I. M., Eunson, K. M., & Bishop, S. (1986). A two eaters. Journal of Consulting and Clinical Psychology,
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tion of both. Journal of Affective Disorders, 10, 67±75. M. E. (1984). Effects of social skills training, amitripty-
Brandon, T. H., Tiffany, S. T., Obremski, K. M., & Baker, line and psychotherapy in unipolar depressed women.
T. B. (1990). Postcessation cigarette use: The process of Behavior Therapy, 15, 21±40.
relapse. Addictive Behaviors, 15, 105±114. Holcomb, W. R. (1986). Stress innoculation therapy with
Brown, T. A., & Barlow, D. H. (1992). Panic disorder with anxiety and stress disorders of acute psychiatric inpa-
agoraphobia. In P. H. Wilson (Ed.), Principles and tients. Journal of Clinical Psychology, 42, 864±872.
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G. T. (1986). Understanding and preventing relapse. Hooley, J. M., & Teasdale, J. D. (1989). Predictors of
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Clark, D. M., Salkovskis, P. M., Gelder, M., Koehler, K., marital distress and perceived criticism. Journal of
Martin, M., Anastasiades, P., Hackman, A., Middleton, Abnormal Psychology, 1, 14±26.
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panic. In I. Hand & H. U. Wittchen (Eds.), Panic and Relapse rates in addiction programs. Journal of Clinical
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Clark, D. M., Salkovskis, P. M., Hackman, A., Middleton, Kabat-Zinn, J. (1990). Full catastrophe living: The program
H., Anastasiades, P., & Gelder, M. (1994). A comparison of the stress reduction clinic at the University of
of cognitive therapy, applied relaxation and Imipramine Massachusetts Medical Center. New York: Dell.
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Psychiatry, 164, 759±769. S. (1992). The naturalistic history of bulimia nervosa:
Craske, M. G., Brown, T. A., & Barlow, D. H. (1991). Extraordinarily high rates of chronicity, relapse, recur-
Behavioral treatment of panic disorder: A two year rence and psychosocial morbidity. International Journal
follow-up. Behavior Therapy, 22, 289±304. of Eating Disorders, 12, 1±9.
Cummings, C., Gordon, J. R., & Marlatt, G. A. (1980). Keller, M. B., Shapiro, R. W., Lavori, P. M., & Wolfe, N.
Relapse: Strategies of prevention and prediction. In W. (1982). Relapse in major depressive disorder: Analysis of
R. Miller (Ed.), The addictive behaviors: treatment of the life table. Archives of General Psychiatry, 39,
alcoholism, drug abuse, smoking and obesity 911±915.
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Emmelkamp, P. M. J., & Kuipers, A. C. M. (1979). Chevron, E. (1984). Interpersonal psychotherapy of
Agoraphobia: A follow-up study four years after depression. New York: Basic Books.
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M., Grove, W. M., Garvey, M. J., & Tuason, V. B. for maintenance and generalization. The Cognitive
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6.12
Use of Self-help Books in the
Practice of Clinical Psychology
MICHAEL V. PANTALON
Yale University School of Medicine, New Haven, CT, USA

6.12.2 CATEGORIZATION OF SELF-HELP BOOKS 266
6.12.2.1 Standardized Therapy Manuals 266
6.12.2.2 General Self-help Books 267
6.12.2.3 Problem-focused Self-help Books 267
6.12.2.4 Technique-focused Self-help Books 267
6.12.2.5 Internet Self-help Books 267
6.12.2.6 Educational Self-help Books 267
6.12.2.7 Other Self-help Books 268
6.12.3 OVERALL EFFECTIVENESS OF SELF-HELP BOOKS 268
6.12.4 EFFECTIVENESS OF EACH TYPE OF SELF-HELP BOOK 269
6.12.4.1 General Self-help Books 269
6.12.4.2 Problem-focused Self-help Books 269
6.12.4.3 Technique-focused Self-help Books 270
6.12.4.4 Internet Self-help Books 270
6.12.5 RECOMMENDATIONS FOR FUTURE RESEARCH 271
6.12.6 INTEGRATING SELF-HELP BOOKS INTO THE PROCESS OF PSYCHOTHERAPY 271
6.12.6.1 Selection 272
6.12.6.2 When to Use Self-help Books 272
6.12.6.3 Introducing and Assigning Self-help Books 273
6.12.6.4 Addressing Nonadherence 273
6.12.7 HOW SELF-HELP BOOKS CAN IMPROVE PSYCHOTHERAPY OUTCOMES 274
6.12.8 POTENTIAL RISKS AND LIMITATIONS OF SELF-HELP BOOKS 274
6.12.9 SUMMARY AND CONCLUSIONS 275
6.12.1 INTRODUCTION Stephens, & Calhoun, 1990; Starker, 1986; 1988;

1990). In this chapter, SHBs will be broadly
Review articles and meta-analytic studies defined as the use of bibliotherapy and other
have suggested that the use of self-help books written, psychotherapeutic materials that are
(SHBs) is an effective adjunctive treatment in the usually read independent of a health profes-
practice of clinical psychology (Gould & Clum, sional. It seems likely that this effectiveness is
1993; Marrs, 1995; Pantalon, Lubetkin, & due to the great appeal and availability of SHBs
Fishman, 1995; Pardeck, 1990; Scogin, Bynum, to the general public, including those who read
265
266 Use of Self-help Books in the Practice of Clinical Psychology
them as study participantsÐmore than 2000 conjectured that this commercialization is

SHBs are published annually (American Psy- mainly due to the market pressures to sell such
chological Association, 1989)Ðas well as the books. Rosen believes that an SHB simply
study of SHBs which are based on empirically cannot present psychotherapeutic techniques in
supported psychological interventions (see an adequate manner, and therefore unlikely to be
Gould & Clum, 1993). Whether based on their sufficiently effective. Further, because SHBs
great appeal, effectiveness, or other reasons, may not accurately diagnose and because read-
SHBs are widely prescribed by psychotherapists ers usually do not adequately comply with the
to their patients. One estimate of the number of recommendations therein, Rosen states that
therapists who have ever assigned a SHB to a SHBs should not be used as a substitute for
client is 60% (Starker, 1988), and the number of psychotherapy (Rosen, 1987). Although there
therapists who prescribe SHBs on a regular basis have not been calls to have SHBs replace
ranges from 55% to 88% (Marx, Gyorky, psychotherapy, this author agrees that the high
Royalty, & Stern, 1991; Starker, 1986, respec- degree of enthusiasm over some SHBs may have
tively). In addition, favorable therapist and led to an overstatement of their effectiveness.
client ratings of the helpfulness of a variety of Other authors disagree with Rosen's claims and
SHBs has been documented (Starker, 1986, suggest that an individual's ability to profit from
1988). a wide variety of SHBs is great (Mahoney, 1988;
Though the popularity of SHBs may have Starker, 1988). This author agrees with the
given rise to the empirical evaluations of their statement that SHBs can be very helpful, but
effectiveness, relatively few studies have been identifying the various conditions under which
published on the critical factors which bear on this can occur, and for whom, is crucial to
their selection and appropriate use. Because advancing our knowledge in this area. This
information on these factors is unavailable, it is chapter will also attempt to address such issues.
unclear whether the general public or the In the following sections, this author will first
relatively large number of therapists who are categorize the various types of SHBs available
assigning SHBs to their clients are selecting the today. Second, the available empirical studies
most appropriate and/or effective SHBs. An- on the effectiveness of SHBs, when used alone
other question regarding SHBs is whether their and with therapist contact, will be reviewed.
use is closely monitored by the prescribing Third, the great appeal of SHBs will be
therapist or whether they are merely suggested discussed along with the manner in which this
to clients, and not integrated into the course of appeal can be used to increase the under-
therapy. Despite these and other unanswered standing of and adherence to psychotherapeutic
questions, this author believes that SHBs have interventions, and can therefore enhance clin-
the potential to provide effective treatments, as ical results. Finally, this chapter will include a
well as to increase client involvement in the description of an approach for integrating SHBs
process of therapy and perhaps, improve its into the course of psychotherapy, which could
outcomes. These ideas are timely given the be applied to various forms of psychotherapy.
continued popularity of SHBs and the increase Specific recommendations for selecting, assign-
in managed care which sometimes severely ing, and using SHBs in the context of a clinical
limits the availability of psychotherapy sessions practice will be offered, along with identifying
to its consumers. This author believes research both the client and therapist variables that
on SHBs could be undertaken in a more appear to be crucial in the effective use of SHBs.
systematic manner if the various types of SHBs
available to the public were better defined and
categorized, and if the degree to which readers
6.12.2 CATEGORIZATION OF SELF-HELP
follow the recommendations given in SHBs is
BOOKS
assessed. Such improvements would allow
empirical investigations of each type of book 6.12.2.1 Standardized Therapy Manuals
separately and comparisons among different
SHBs, as well as information regarding the best Standard therapy manuals (STMs) describe a
way to use SHBs. This chapter will address these standardized treatment protocol to be used in
and other issues regarding the use of SHBs in the conjunction with psychotherapy. They are
practice of clinical psychology. therapist-directed and usually in an outline
There has been a long-standing controversy format. Both therapist and client versions are
surrounding the use of SHBs. Rosen (1987) usually available. In essence, they are used as
stated that SHBs ªcommercializeº (p. 46) psy- therapy guides. They are more technical than
chotherapy by making overgeneralized state- easy-reading, which differs from what one might
ments about psychological problems and their generally find in a local bookstore in the self-help
causes, and by promising unrealistic results. He section. Marsha Linehan's (1993) treatment
Categorization of Self-help Books 267
manual for borderline personality disorder is an 6.12.2.4 Technique-focused Self-help Books

example of an STM. Each chapter of Linehan's
manual for dialectical behavior therapy illus- These are similar to problem-focused SHBs,
trates in great detail the goals, methods, and but instead focus on a specific technique, rather
objectives which will be used in treatment, than a disorder, that could be used for several or
similarly to what one would find in therapy many problems. Unlike the previous SHBs,
sessions. It is considered a type of SHB because these are usually therapist-assisted, because
the client manual specifies tasks that clients can therapists are usually the ones to recommend
do on their own (e.g., homework). Other these books to their clients. However, they can
examples of STMs are Mastery of your anxiety also be self-administered. Examples of SHBs are
and panic (Barlow & Craske, 1989) and Problem The anxiety and phobia workbook (Bourne,
drinkers: Guided self-change treatment (Sobell & 1990) and The relaxation response (Benson,
Sobell, 1993). 1975). As above, these books can be used by
therapists from a wide variety of orientations.
6.12.2.2 General Self-help Books 6.12.2.5 Internet Self-help Books
These do not address specific disorders, but These are defined as any of the preceding
rather general emotional, relationship, or life SHBs that are found on the Internet. This
development issues without delineating specific category challenges the traditional notion of the
techniques and homework exercises within a genre that self-help is an individual helping him-
structured protocol. They are usually self- or herself with the use of materials written by
administered, but can also be therapist-assisted. another or several individuals. Once this
Examples of such SHBs are The road less material is formatted for the Internet, however,
traveled (Peck, 1978) and Notes to myself the opinions, advice, and counsel of potentially
(Prather, 1970). General SHBs can be used by thousands of other, mostly lay, but some
therapists from a wide variety of orientations professional, people can be accessed via chat-
because they do not espouse any particular rooms, message boards, and e-mail. The advice
brand of therapy over another. Instead, they obtained from such sources can be quite
can be used to motivate clients to address personalized, because of the Internet user's
problems which they may have avoided for ability to e-mail or post very specific questions
some time or they can help clarify the goals and about their condition and/or treatment. How-
objectives of psychotherapy. ever, for the purposes of this chapter, it shall be
considered self-help as long as individuals are
not seeking direct consultation with a psy-
chotherapist. Some of the examples of SHBs
6.12.2.3 Problem-focused Self-help Books
listed above are actually on the Internet (albeit
These address a particular disorder (some in severely condensed form), but many Internet
actually assist the reader in diagnosing him- or SHBs are not in the form of a book per se, but
herself) and delineate specific techniques and are rather in the form of a homepage with a
homework exercises within a structured proto- myriad of options for further information or
col. They are usually self-administered, but can directions to other resources depending upon a
also be therapist-assisted. Examples of this type reader's specific interests. These ªbooksº are
of SHB are Stop obsessing (Foa & Wilson, usually self-administered or with the assistance
1991), Control your depression (Lewinsohn, of ªonline therapists.º The reader is referred to
Munoz, Youngren, & Zeiss, 1992), Coping with Dow, Kearns, & Thornton (1996) for a list self-
depression (Blackburn, 1987), and The feeling help sites.
good handbook (Burns, 1989). Although these
are all examples of cognitive-behavior therapy 6.12.2.6 Educational Self-help Books
(CBT) books, problem-focused SHBs are also
written from a psychodynamic perspective These attempt to help the patient, spouse,
(Bass & Davis, 1997). Problem-focused SHBs family member, or significant other learn more
can be used by therapists with a wide variety of about the problems the identified patient is
therapeutic orientations (e.g., behavioral, psy- experiencing, and their prevalence, treatment,
chodynamic, interpersonal) for a wide variety of and course, as well as ways in which to
problems. However, it is advisable that they be effectively cope with the patient. This type of
used by therapists and clients who are prepared book is often helpful because it can shorten the
to systematically apply problem-solving and educational process, allow patients and their
other techniques to a specific problem or families to become collaborators rather than
symptom. passive recipients of treatment, and enhance
adherence to treatment recommendations strating the effectiveness of the techniques

(Mueser, 1994). A number of such books have therein (e.g., graduated exposure with response
been written for many of the psychotic, prevention). However, the book itself (i.e., how
affective, and anxiety disorders, such as Surviv- the treatment works when a client reads about it
ing mental illness: Stress, coping, and adaptation and decides on his or her own to what degree he
(Hatfield & Lefley, 1993) which pertains largely or she adheres to the recommendations) has not
to schizophrenia, When once is not enough: Help been empirically tested in controlled trials.
for obsessive-compulsives (Steketee & White, However, others have been empirically tested
1990), or Panic disorder: The facts (Rachman & in this manner, such as Burns (1989). Because an
de Silva, 1996). A lengthier list of other SHB presents psychotherapeutic techniques in a
organizations, SHBs, and resources for educat- unique manner, it can have a very different
ing both patients and their families about impact on a client as compared with the impact
psychological disorders has been prepared by of seeing a therapist, even if the therapist and the
Mueser (1994). author of the SHB are presenting the very same
techniques. This is true, in part, because
rationales for the use of therapeutic interven-
6.12.2.7 Other Self-help Books tions may differ significantly from those pre-
sented in an SHB, and because different
Finally, there are some SHBs which do not
rationales can lead to very different perceptions
fall into one of the above categories. These are
about treatment and outcome (Newman, 1994).
books that are not explicitly intended as self-
For some individuals, the therapist could be
help, but rather are books (e.g., novels,
more motivating because he or she represents
biographies) which, for example, chronicle a
another human being expressing understanding
well-known individual's life or attempts to cope
of the client's problems, but for others an SHB
with a particular problem which is in some way
could be more effective because it is less
instructive, such as Darkness visible by William
personally threatening.
Styron (1990), Pulitzer prize-winning fiction
Gould and Clum's (1993) meta-analysis of 40
writer. Most of these SHBs are self-adminis-
self-help studies resulted in a measurable overall
tered, but when they are used with the assistance
effect size for self-help interventions of 0.76 at
of a therapist, it is usually within the framework
post-treatment and 0.53 at follow-up, which is
of psychodynamic psychotherapy (Pardeck,
comparable to those reported for psychother-
1991). However, their use in other types of
apy (Stiles, Shapiro, & Elliot, 1986). This effect
psychotherapy, as with general SHBs, is not
was strongest when SHBs were compared
contraindicated, because they usually serve to
to no treatment conditions (e.g., wait-list and
motivate efforts to change and give clients a
delayed-treatment controls) and when beha-
lexicon with which to better describe their
vioral observations were used as the dependent
complaints. Unfortunately, there are no con-
measure (e.g., behavioral avoidance test). The
trolled studies, known to this author, testing the
lowest effect sizes were found when SHBs were
efficacy of this type of SHB. In the next section,
compared to placebos (e.g., attention control
the effectiveness of SHBs in general is reviewed,
conditions) and when physiological instruments
followed by a summary of the research on each
(e.g., heart rate) were used as the dependent
of the above SHB categories.
measure. Another meta-analysis, conducted by
Marrs (1995), found a positive, though some-
6.12.3 OVERALL EFFECTIVENESS OF what smaller effect size for SHBs (0.57), but no
SELF-HELP BOOKS significant differences between SHBs and
therapist-assisted treatments. In both of these
Although the treatments found in many more recent meta-analyses, SHBs for assertion
SHBs are usually not empirically supported, training, anxiety, and sexual dysfunction were
there are some significant exceptions and the more effective than those for weight loss,
number is increasing (Blackburn, 1987; Burns, impulse control, and studying problems.
1989; Clum, 1990; Ellis & Tafrate, 1997; Foa & Additionally, Gould and Clum found that the
Wilson, 1991; Lewinsohn et al., 1992). However, mean effect size for pure self-help conditions
even though there are some books which are (with no therapist contact at all) was greater
based on empirically validated treatments, than that of the minimal therapist contact
many of the SHBs themselves are not evaluated conditions (where therapists periodically helped
directly, though once again there are notable patients with the materials). However, the mean
exceptions (e.g., Burns, 1989; Clum, 1990; effect size for self-help conditions was less than
Lewinsohn et al., 1992). For example, Foa & that of the therapist-assisted conditions. The
Wilson's (1991) book is based on a good deal of mean effect size for self-help conditions (SHB
methodologically sound research study demon- assigned with no therapist contact) was also less
Effectiveness of Each Type of Self-help Book 269
than that of the combination of self-help and theories of the author. Another reason why they
therapy (assignment of an SHB plus periodic are difficult to investigate in research is that the
therapist supervision). An important difference advice described within them often appears to
is that SHB plus therapy was a more intensive be overgeneralized and superficial. Despite the
integration of therapy and self-help regimens above shortcomings of general SHBs, their
than the minimal contact conditions. Obviously popularity is staggering. However, this popu-
there is a need for more research in this area so larity has not prompted much empirical
that a definitive statement about usefulness of investigation, and thus, very little data are
SHBs and their combination with psychother- available regarding the impact of these books
apy can be made. Interestingly, in the Marrs (Starker, 1990). Therefore, it would be difficult
(1995) study, the amount of contact the at this stage to even recommend how they could
therapist made with participants in SHB-only be integrated into the context of psychotherapy
conditions was not significantly correlated with or for what problems. However, it appears that
outcome. However, it appeared that partici- such books (e.g., Peck, 1978) could be effective
pants whose primary goal was weight loss or in helping a patient clarify exactly what
anxiety reduction improved significantly more thoughts, feelings, and/or behaviors are most
with increased therapist contact. distressing. They could also assist the therapist
Thus, it appears that there are mixed results and client in setting goals and objectives at the
when comparing self-help vs. therapist-assisted outset of therapy, especially if the client is
conditions. One hypothesis, put forward by unclear about how he or she hopes to benefit
Gould and Clum (1993) is that the therapist- from the experience. Such books have been
assisted conditions may not adequately resem- described as being helpful in treating physically
ble how a therapist would actually assist a client and/or sexually abused or neglected children
with an SHB in therapy and therefore may not (Pardeck, 1991), though only one controlled
have enhanced the SHBs effectiveness; it may trial has been conducted (Ogles, Lambert, &
have even diminished it to some degree. One Craig, 1991), which demonstrated that a general
factor that may have influenced these results is SHB worked equally well as behaviorally and
the fact that only 15 of the 40 studies analyzed stage theory-based SHB for coping with
by Gould and Clum utilized a clinical sample divorce. General SHBs seem to be utilized
and it is unclear whether SHBs would be as mostly by therapists who are experientially,
effective with patients who consistently met Gestalt, or psychodynamically oriented thera-
specific diagnostic criteria. pists (Pardeck, 1991). This may be because
Although Marrs (1995), based on a sample of these SHBs focus on events (current and/or
nine studies, found that there was no significant historical) which are thought to be the cause of
difference between SHBs and therapist-directed the problem behaviors, rather than on specific
treatments, a definitive statement about procedures to ameliorate them.
whether SHBs are more or less effective than
therapy cannot be made because of the small
number of studies that compare active treat- 6.12.4.2 Problem-focused Self-help Books
ment without an SHB to (i) self-help in general
(only nine were included in Marrs' study), and There are a number of other studies that
(ii) pure self-help conditions (no therapist demonstrate the effectiveness of problem-
contact). focused SHBs for particular disorders. Regard-
ing depression, it appears that reading a
cognitive or behavioral SHB is more effective
6.12.4 EFFECTIVENESS OF EACH TYPE than delayed-treatment groups (Scogin et al.,
OF SELF-HELP BOOK 1990; Scogin, Jamison, & Gochneaur, 1989;
6.12.4.1 General Self-help Books Smith, Floyd, Scogin, & Jamison, 1997; Wol-
lersheim & Wilson, 1991), equally effective as
Although general SHBs sometimes focus on a group CBT (Wollersheim & Wilson, 1991), and
particular area of an individual's life, the exact that cognitive and behavioral books were also
nature of the problem is ill-defined (e.g., low equally effective (Scogin et al., 1989). Treatment
self-esteem, failed relationship), and they do not gains have reported to be maintained or
assist a reader in ascertaining a proper enhanced as long as three years beyond the
diagnosis. Such books also do not offer specific end of self-help treatment (Smith et al., 1997).
techniques and homework exercises within a Additionally, Mahalik & Kivlighan (1988)
structured protocol. For these reasons, these reported that participants who are high on
books are simply more difficult to assess in measures of independence, need for structure,
terms of effectiveness. They are often based on internal locus of control, and self-efficacy, had
the clinical intuition and nonempirically based responded better to a self-help approach to
depression, than those who were low on these et al., 1986). SHBs, based on other models of
attributes. psychotherapy, could thus prove as helpful as
Regarding panic disorder, Ghosh and Marks those above. However, the books that take up
(1987) found that self-exposure instructions the most space in the self-improvement section
worked equally well to reduce anxiety when of a local bookstore (e.g., SHBs on dieting,
given by a psychiatrist, SHB (Coping with panic relationships, parenting, hypnosis), or have
[Clum, 1990]), or computer program, and that been found to sell the best (Starker, 1990) are
each resulted in substantial improvement up to not the ones that have been empirically
six-month follow-up. Gould, Clum, and Sha- validated directly, nor are they based on
piro (1993) similarly found that the effectiveness treatments shown to be effective in research
of an SHB was not significantly different from studies (Marrs, 1995). Conversely, some SHBs
that of individual guided imaginal coping. Both that are based on empirical data do not sell
treatments were significantly more effective nearly as well as those that are not based on such
than a wait-list control group. In a follow-up information, perhaps because claims regarding
to the above study, Gould and Clum (1995) change and its maintenance are more realistic in
concluded that the SHB Coping with panic the former (Mahoney, 1988). However, as
(Clum, 1990) was significantly more effective consumers of health care become more sophis-
than a wait-list control group at post-treatment ticated in their knowledge of available treat-
and at two-month follow-up. Lidren et al. ments, which this author believes to be a by-
(1994) also report that Coping with panic is as product of managed care, the demands to
effective as group therapy based on the same publish SHBs with some empirical support vs.
book, which was required reading, and more the need to make such books appealing to the
effective than a wait-list control. general public may become less competing.
Ogles et al. (1991) report findings from one of
the few studies to compare problem-focused
books based on different therapeutic orienta- 6.12.4.3 Technique-focused Self-help Books
tions, namely behavior therapy and stage theory
A number of very clearly written workbooks
for the treatment of reactions to divorce. These
on specific techniques for coping with various
books were also compared to a general SHB,
problems (e.g. tension headaches, depression,
which focused broadly on coping with life events
anxiety) have been written. Some popular
(not only divorce). It was found that all three
examples are The anxiety and phobia workbook
were effective in reducing a variety of symptoms
(Bourne, 1990) and The relaxation response
associated with loss, but that they all worked
(Benson, 1975), and Mind over mood (Green-
equally well. In addition, those who reported
berger & Padesky, 1995). Although some of the
high expectations of being helped fared better
techniques therein have been empirically de-
than those who did not, as evidenced by greater
monstrated to be effective, especially those in
reductions in symptom scores, and attributed
Benson (1975), the use of the books by clients on
the change largely to their reading of the books.
their own or with minimal therapist contact has
Other behaviors, such as problematic drink-
not. Perhaps this is partially due to the fact that
ing (Heather, Robertson, MacPherson, Allsop,
such books seem most appropriate for use as a
& Fulton, 1987; Hester & Delaney, 1997; Miller
supplement to the training of clients in various
& Taylor, 1980; Sobell & Sobell, 1993) and
techniques (e.g., progressive muscle relaxation).
smoking cessation (Glasgow, Schafer, &
Oftentimes, they do not offer an entire treat-
O'Neill, 1981) have also been shown to be
ment plan for addressing all the various aspects
modifiable with the use of SHBs. Heather et al.
of a problem (e.g., behavioral, cognitive,
(1987), in particular, demonstrated that a
interpersonal), as does a problem-focused book,
problem-focused book on controlled drinking
and may therefore be difficult to assign and test
was more effective than an educational book
for a particular disorder. However, it is
regarding alcohol problems. In addition, many
conceivable that their effectiveness in reducing
of these studies report maintenance of gains at
some circumscribed aspect of a disorder (gen-
six months, and one, two, and three years.
eral anxiety or feelings of hopelessness), or in
Hester and Delaney (1997) and Gould and
treating subclinical samples, could be empiri-
Clum (1995) have also demonstrated that
cally tested.
computerized SHBs are also effective.
In summary, the SHBs in this category which
have some level of empirical support have been 6.12.4.4 Internet Self-help Books
based predominantly on CBT. Thus, more
research is required in other areas, as meta- At the time of writing, there are no controlled
analytic studies inform us that overall, most trials on Internet SHBs. As described earlier,
psychotherapies are equally effective (Stiles Internet SHBs could greatly expand the number
Integrating Self-help Books into the Process of Psychotherapy 271
and type of SHBs to be tested. The Internet also investigating what aspects of SHBs (e.g.,
adds a new medium to test. For example, the instillation of hope via case examples vs.
difference between the effectiveness of an SHB techniques) account for the most change in
that is read in the traditional manner vs. one clients' behavior, would also be helpful. Both of
that is read on the World Wide Web could be these issues will be discussed in a later section of
illuminating. Internet books have the potential this chapter.
to make SHBs significantly more personalized In summary, although a carefully selected
via their potential to cross-reference a greater and closely read SHB, without any assistance
amount of information than a traditional SHB from a therapist, may be good enough for some,
(see Dow et al., 1996). the available data do not speak to the
characteristics of such individuals. Thus, a
more conservative approach, one consisting of
6.12.5 RECOMMENDATIONS FOR an SHB plus therapy, may be warranted at this
FUTURE RESEARCH stage, given that the data are not conclusive and
the fact that only a small number of SHBs have
It is recommended that statements regarding been empirically validated for use alone.
the effectiveness of SHBs should be made based Another reason why this approach might be
on a careful investigation of specific types of more advantageous is that readers/clients would
books separately with more attention paid to have guidance in how to select an SHB and how
the characteristics of individuals who can to adequately adhere to its recommendations.
benefit from them and the experimenters/ Poor selection and nonadherence are among the
therapists who utilize them. More controlled most deleterious results of an unstructured
trials comparing the effectiveness of the various approach to self-help (Rosen, 1987). Therefore,
types of SHBs, especially those in the general, because of the tentative nature of the research
technique, Internet, and other categories would on SHBs, this author believes that psychother-
be helpful toward this end. Research on the apy, supplemented by judicious use of SHBs, is
characteristics of participants, such as reading a safe and useful alternative to the pure self-help
and grade level, expectations of change, and approach. Perhaps future research will explicate
motivation, should be addressed (Marrs, 1995). further under what conditions this may be the
The issue of subject selection is also important. case and under what conditions a pure self-help
Perhaps individuals who typically read SHBs approach may be indicated. Despite the fact
differ substantially from those who do so merely that the prescription of self-help books and
to be in a study for which they will receive some other materials is widespread, little research
evaluation and/or financial remuneration. In- regarding various methods for assigning SHBs
vestigations of the difference in outcomes to clients or incorporating them into the course
between individuals who are permitted to read of therapy has not been undertaken. Future
and apply the precepts of the book on their own research should address this and the aforemen-
vs. those who have periodic reviews with the tioned questions as it suggests the possibility of
experimenter, could be illuminating. Perhaps using SHBs to enhance psychotherapy out-
the use of diary recordings of progress and comes. It is hoped that the following guidelines
issues during reading would obviate the need for for integrating SHBs in the practice of clinical
such frequent contacts with the experimenter. psychology, which have been helpful in this
Such frequent contacts may contaminate the author's work with clients, could facilitate such
findings of self-help research in two important research.
ways: (i) the contact with the therapist, rather
than with the SHB, may account for some, if not
all, of the improvement noted; and (ii) similarly 6.12.6 INTEGRATING SELF-HELP BOOKS
demand characteristics, rather than the SHB, INTO THE PROCESS OF
may elicit some portion of the improvement PSYCHOTHERAPY
noted. However, research which compares the
effectiveness of psychotherapy, with and with- Many studies testing the effectiveness of
out SHBs is not available at this time. SHBs do not clearly state how the books are
Therapist characteristics which bear on the to be used. Some authors, however, have
effectiveness of SHBs, which pertain mostly to addressed related issues, such as the prescrip-
the manner in which they are utilized and tion of SHB (Pardeck, 1990; Starker, 1990);
monitored in treatment (e.g., prescribed vs. which clients benefit most from a self-help
suggested, monitored closely or informally), approach (Mahalik & Kivlighan, 1988); and
should also be addressed in future research so bibliographies of SHBs (Quackenbush, 1991).
that practitioners may have guidance on how to However, only Pantalon et al. (1995) and
make good use of such books. In addition, Pardeck (1991) have detailed a model of fully
integrating SHBs into the course of psychother- mended, as it can help clients, and therapists of
apy. A brief overview of the former approach is any orientation develop realistic expectations
given below. for behavior change.
6.12.6.1 Selection 6.12.6.2 When to Use Self-help Books

Before a therapist can adequately help select The second step in integrating SHBs into the
the SHB that will be best for a client, it is helpful course of therapy involves deciding when and
for him or her to be aware of the most frequently why to use them. When clients are experiencing
cited positive characteristics of such books. difficulty understanding the nature of the
These are: (i) optimistic frame, (ii) encourage- problems they are facing, when the direction
ment, (iii) advice to seek professional help, (iv) therapy should take is somewhat unclear, when
general self-understanding, and (v) understand- clients either resist or have difficulty prioritizing
ing about specific problems (Halliday, 1991). goals, are only some examples of when SHBs
This author believes that, in addition to the can be used. A general rule of thumb, however,
above, one of the most valued aspects of SHBs is is that the use of SHBs could be effective at a
the social validation offered through their point when either or all of these three situations
suggestion that problems are understandable arise:
given life experiences, and that the readers are (i) the client is asking many questions about
not to blame. Hence, fear of embarrassment or his or her symptoms or the process of therapy
evaluation by a therapist are nonexistent. Also, (ªHow is this going to help me?º or ªHow do
instead of a complex diagnosis, the reader is you know this is right for me?º);
given simple, easy-to-understand explanations (ii) the client is resistant in some way and/or
for why they are the way they are, via accounts does not adhere to therapeutic exercises (e.g., ªI
of cases which often mirror their own personal can't understand why you want me to do this
experiences. They also raise motivation to homework?º); or
change through examples of others who have (iii) the client appears to be of the belief that
succeeded. They typically offer an optimistic he or she is the only person that is attempting to
outlook on problems and a multitude of cope with such problems, which may accom-
suggestions for better coping. In addition, they pany a sense of helplessness (e.g., ªNo one else
are perceived by readers to be more efficient has such major problems; I just can't do any-
than therapy, especially in terms of time, cost, thing about itº).
and effort (Starker, 1986). In these situations, an SHB could bolster the
This author believes that SHBs will be able to therapist's explanation of a problem, clarify the
offer all of the above, if they are goal-directed process of treatment, offer motivation and
and written in a clear and user-friendly format rationales for doing therapeutic exercises, nor-
(e.g., tables, figures, charts). They should also malize symptoms, and give hope.
offer the reader a multitude of therapeutic How ready a client is to engage in actual
exercises with rationales and encouragement, strategies to change behavior may affect how
and descriptions of methods to measure notice- effectively he or she utilizes the advice in a
able changes (e.g., charts, checklists). In an particular type of SHB. For example, if a client
effort to promote self-acceptance, it should is still thinking about whether or not he or she
prepare readers for setbacks or failure. In this has a problem in the first place or whether he or
author's opinion, however, the two most she believes anything can be done about it, or
important things an SHB should offer a reader whether the costs of change are too great, he or
are research-based information and a plethora she may not be motivated to read a book which
of case examples of those treated successfully, so offers specific advice regarding how to change
that readers can identify with the case examples behavior directly. Instead they may profit from
in a book and be convinced that they have a book or a section of a book that discusses the
selected an SHB that is appropriate to their pros and cons of their behavior first (e.g.,
needs. Both have also been demonstrated in general SHB or the ªdiagnosisº section of a
research to significantly impact on expectancies problem-focused book). This then impacts on
for therapeutic change (Kazdin & Kranse, what type of book the theorist should assign to
1983). The reader is referred to Pantalon et al. the client. One way to assess this is by using one
(1995) and Santrock, Minnett, and Campbell of the various stages of change assessments
(1994) for bibliographies of SHBs recom- available which have been shown to correlate
mended for use in the practice of clinical with actual attempts to change and which are
psychology. Seligman's (1994) What you can useful in planning clinical strategies (Prochaska,
change and what you can't is strongly recom- DiClemente, & Norcross, 1992).
Integrating Self-help Books into the Process of Psychotherapy 273
6.12.6.3 Introducing and Assigning Self-help This author believes that it is almost always
Books better to prescribe an SHB rather than give the
patient a choice of reading it or not. The more
The rationale for asking a client to use an SHB confident, directive, and positive a therapist is
in conjunction with therapy should be planned when assigning an SHB, the better the chance
after the therapist has (i) decided on the target the SHB has of making a therapeutic impact on
problem; (ii) conceptualized his or her reason for the client. Therapists should also display high
seeking additional materials (e.g., client is asking regard for the selected SHB. Therefore, SHBs,
many questions about the process of therapy); and the exercises therein, are almost always
(iii) formulated his or her criteria for selecting an assigned as homework, which is monitored by
SHB; and (iv) selected an SHB, as well as, the the therapist on a regular basis.
introductory selections he would like the client to
read. It may be best not to suggest exercises other
than reading for the first two sessions after 6.12.6.4 Addressing Nonadherence
introducing an SHB, even if the client has
already practiced such exercises prior to adding We have found that it is usually more effective
the book. Once all four conditions have been met to integrate SHBs into the context of therapy
the therapist can introduce the SHB he or she has rather than to simply assign them. If they are
selected following the suggestions found in the not an integral part of the therapy, the patients
next several sections. may devalue such books, behavioral homework
When introducing the idea of using an SHB to assignments, and even the therapy itself. If they
a client, begin with a review of what gains the are not good or relevant enough to use
client has made thus far and how. It is then systematically, their use should be seriously
explained that if these efforts were extended, questioned. This is true even if a therapist is only
during nontherapy days and with new exercises, using one section of a particular book. How-
such as with the help of an SHB, greater ever, some patients simply will not comply with
improvements could be achieved. The client is such prescriptions as described above and will
then asked for his or her thoughts on this. require more in the way of motivation to
Subsequently, the author shares some of his actively change problematic behaviors (e.g., a
book selection criteria with the clients and change in type of SHB). Readers of SHBs can
points out the ways that the SHBs generally mistakenly believe that reading a book, but
used by this author are different from other failing to follow through on specific assign-
titles (e.g., research-based), many of which their ments, constitutes being actively engaged in the
friends may adore. If a client appears motivated changing behavior.
to integrate an SHB into the work of therapy, Due to the above, the following suggestions
then this author informs the client about the are made for dealing with nonadherence when
appropriate and reasonable expectations for using an SHB:
what can be gained from reading an SHB. The (i) self-monitoring, which allows clients to
degrees of behavior change and change as a become more aware of their resistant behavior,
process is emphasized. The client is told that the because a lack of such awareness may be
learning does not necessarily end by the time he stopping a client from acknowledging the
or she finishes reading the book, but that it severity of their problem;
continues and the SHB becomes a reference, (ii) shaping of behavior, which involves
which the reader can go back to time and time positively reinforcing (e.g., giving praise, feed-
again. This author then goes through the table back, or acknowledgment for) each incremental
of contents of the book with the client, effort toward more compliant behavior;
remarking on how each of the sections (iii) agreeing on relevant sections. Frequent
(preselected by the therapist) is relevant to the reevaluation of therapy goals and objectives
client's particular problems and treatment. This facilitates this, and allows for a pace that is
exercise is sometimes quite illuminating because comfortable for both;
it makes it clear how therapist and client (iv) assessing therapist demands regarding
conceptualizations of the primary problems or change. If a therapist is vigilant about monitor-
methods of addressing them differ. Therefore, ing his or her irrational expectations, then the
the therapist must be flexible at this early stage chances of making unrealistic demands of the
and willing to compromise on certain selections client, and hence of noncompliance, can be
or exercises that the client may or may not see as minimized;
relevant at first. This process of introducing and (v) anticipating nonadherence, which gives
assigning an SHB also usually helps clients the therapist an early opportunity to plan
develop their own criteria for future self-help strategies for addressing this issue. However,
selections made on their own. it also allows the therapist to view such resistant
behavior as part of the process of change, rather (iv) when the book selected is not written in
than as an annoyance or interference. With this terms the reader can understand; or
attitude, the therapist can respond to nonad- (v) when it does not match the goals of the
herence in a nondefensive, reflective manner, reader.
which can be critical in motivating resistant Since the psychotherapy plus SHB approach,
clients; and described above, addresses each of these condi-
(vi) traditional CBT techniques (e.g., desen- tions, it should help the therapist avoid the
sitization, cognitive restructuring). potential risks associated with SHBs. Unfortu-
nately, diligent attempts on the part of the
therapist to ensure that each of these conditions
6.12.7 HOW SELF-HELP BOOKS CAN is met does not always guarantee good outcome
IMPROVE PSYCHOTHERAPY with an SHB. One of the most important aspects
OUTCOMES of using an SHB, as with any problem-focused
therapy, is to achieve a good balance between
Therapists may be able to enhance their
efforts toward change and efforts toward accep-
effectiveness by adding SHBs to their arma-
tance (Hayes, Jacobson, Follette, & Dougher,
mentarium. In general, the manner in which
1994; Linehan, 1993). Thus, therapists attempt-
SHBs could do this is by offering to therapists a
ing to integrate an SHB into the course of
new medium through which they can motivate
therapy should remember that at certain points
behavior change. Specifically, SHBs can:
he or she should either put the SHB (e.g., change
(i) increase the number and variety of ratio-
effort) aside (with the mutual agreement that this
nales given for treatment interventions, via case
is only a temporary change) or change the type of
examples and interesting anecdotes in under-
SHB that is being used (e.g., change from a
standable language;
problem-focused to a general SHB, which pro-
(ii) increase opportunities to self-monitor
motes more self-understanding or acceptance).
problem behaviors as well as to rehearse
One of the fundamental limitations of
adaptive ones, through the many therapeutic
psychotherapy manuals in general, and SHBs
exercises they offer;
in particular, is the assumption that the same
(iii) enhance adherence to homework by
disorder manifested by different people, with
offering the client motivational accounts of
different learning histories and contingencies
other clients and breaking down complex tasks
that maintain the symptoms, are to be treated in
into their component parts;
the same manner. Fishman (1981) refers to this
(iv) increase self-efficacy via a heightened
as mistaking ªtopographical equivalenceº for
sense that they themselves (rather than the
ªfunctional equivalenceº (p. 244). In order to
therapist) are solving their problems; and
treat an individual effectively, the therapist may
(v) improve generalization to other settings,
need to functionally assess each of the client's
because their suggestions are read and imple-
problematic behaviors so as to fully understand
mented in a wide variety of situations outside of
the reinforcement contingencies and how they
the therapy office.
relate to each problem area. Assuming that the
same behavior exhibited by two individuals,
6.12.8 POTENTIAL RISKS AND compulsions related to unwanted, intrusive
LIMITATIONS OF SELF-HELP thoughts (i.e., topographical equivalence) serves
BOOKS the same function in both (i.e., functional
equivalence), such as avoidance of intimate
Rosen (1987) suggests that the potential risks relationships vs. a desire to always be in control
associated with the use of SHBs are associated of one's thoughts, may lead the therapist to
mainly with the misdiagnosis of problems, lack implement minimally helpful interventions.
of adherence with procedures, overgeneralized Thus, when using an SHB in therapy, it would
advice, and overstatement of the effects of SHBs. be advisable for the therapist to individualize its
However, this author believes that these risks are procedures, either by timing or choosing the
associated with the misuse of SHBs, rather than interventions or target behaviors in such a way
by the books themselves. Specifically, SHBs may that they are reasonable given the client's entire
not help produce positive behavior change when clinical picture (e.g., symptoms, motivation,
the following conditions exist: social support, family life, occupational func-
(i) when expectations of change are unrea- tioning, strengths and weaknesses). For exam-
listic; ple, an empirically validated SHB for
(ii) when specific directions are not followed; generalized anxiety disorder may begin the
(iii) when an irrelevant or inappropriate course of treatment with progressive muscle
book is selected (e.g., due to a misunderstanding relaxation, which for some may be anxiety-
of the various types of books available); provoking, rather than relaxing. For such cases,
References 275
reframing, or more assessment may be indi- the course of psychotherapy, with specific
cated. Without a functional analysis of each of recommendations for selecting, assigning, and
this client's problem areas, the therapist might using SHBs in the context of a clinical practice;
have incorrectly assumed relaxation training to (v) the manner in which SHBs could enhance (a)
be the best intervention with which to start. clinical results, especially via a better under-
In fact, many of the issues that impinge on the standing of and adherence to psychotherapeutic
use and effectiveness of manualized treatments interventions, generalization, and increased
in therapy also affect the effectiveness of SHBs. efficiency, as well as (b) dissemination of
For example, the degree to which therapists empirically supported treatments to practi-
individualize such manuals affects clinical out- tioners and clients alike; and finally (vi) the
come, and there is great controversy regarding potential hazards associated with the misuse of
whether modifications based on clinical intui- SHBs. It was proposed that if therapists used
tion or actuarial judgment leads to greater SHBs in the manner outlined, SHBs could be an
efficacy of the treatment (Wilson, 1997). How a effective adjunctive treatment in psychother-
therapist individualizes an SHB for use by a apy. It is the belief of this author that, with the
particular client with a unique learning history above issues clarified, future research into the
may impact on its effectiveness in the same way effectiveness of SHBs, including its potential
that it does with treatment manuals. How- positive impact on psychotherapy outcome,
ever, if future research attempts to experimen- may be more systematically addressed.
tally control for differences in administration or
individualization, more could be learned about
the most productive way to do this. One of the ACKNOWLEDGMENT
more basic questions would involve a compar- The author wishes to express his gratitude to
ison of individualization vs. no individualiza- Wendy Bobadilla and Beatrice Martineau for
tion, or individualization with and without their assistance in the preparation of this
formal rules, as has been done with standar- chapter.
dized treatment manuals. The results of such
studies are mixed, but appear to favor actuarial
judgment, which would suggest less individua- 6.12.10 REFERENCES
lization of standardized books. However, it
American Psychological Association (1989). First annual
appears that even those who favor the actuarial golden fleece awards for do-it-yourself therapies. Pre-
side of this debate, suggest that tailoring a sentation at the annual meeting of the American
treatment manual to reduce disruptive beha- Psychological Association, New Orleans, LA.
viors, and enhance adherence and regard for the Barlow, D. H., & Craske, M. G. (1989). Mastery of your
anxiety and panic. Albany, NY: Graywind.
interventions (much in the way described Bass, E., & Davis, L. (1997). Courage to heal: A guide for
above), is both appropriate and improves the women survivors of childhood sexual abuse. New York:
effectiveness of the treatment (Eifert, Schulte, Harper Perennial.
Zvolensky, Lejuez, & Lau, 1997; Linehan 1993). Benson, H. (1975). The relaxation response. New York:
A final purpose SHBs could serve is to further Avon.
Blackburn, I. M. (1987). Coping with depression. Edin-
researchers efforts at wide dissemination of burgh, UK: Chambers.
research findings regarding empirically sup- Bourne, E. J. (1990). The anxiety and phobia workbook.
ported psychotherapeutiic techniques (Persons, Oakland, CA: New Harbinger.
1997). If SHBs based on empirically validated Burns, D. D. (1989). The feeling good handbook. New
York: William Morrow.
treatments became as popular to the general Clum, G. A. (1990). Coping with panic. Pacific Grove, CA:
public as other books, clinicians who would Brooks/Cole.
otherwise be unaware of such treatments might Dow, M. G., Kearns, W., & Thornton, D. H. (1996). The
have an incentive to learn and use them (i.e., if Internet II: Future effects on cognitive behavioral
individuals in therapy were aware of such practice. Cognitive & Behavioral Practice, 3, 137±157.
Eifert, G. H., Schulte, D., Zvolensky, M. J., Lejuez, C. W.,
approaches, it is conceivable that they would & Lau, A. W. (1997). Manualized behavior therapy:
seek such treatment from their therapist). Merits and challenges. Behavior Therapy, 28, 499±509.
Ellis, A. E., & Tafrate, R. C. (1997). How to control anger
before it controls you. Secaucus, NJ: Carol Publishing
Group.
6.12.9 SUMMARY AND CONCLUSIONS Fishman, S. T. (1981). Narrowing the generalization gap in
clinical research. Behavioral Assessment, 3, 243±248.
This chapter reviewed (i) the various types of Foa, E., & Wilson, R. (1991). Stop obsessing: How to
SHBs available today; (ii) the available empiri- overcome your obsessions and compulsions. New York:
cal studies on the effectiveness of SHBs; (iii) the Bantam.
Ghosh, A., & Marks, I. M. (1987). Self-treatment of
possible reasons for the appeal of SHBs to the agoraphobia by exposure. Behavior Therapy, 18, 3±16.
general public and, more recently, to research- Glasgow, R. E., Schafer, L., & O'Neill, H. K. (1981). Self-
ers; (iv) an approach for integrating SHBs into help books and amount of therapist contact in smoking
cessation programs. Journal of Consulting & Clinical cognitive and behavioral therapy. Cognitive & Behavioral
Psychology, 49, 659±667. Practice, 2, 213±228.
Gould, R. A., & Clum, G. A. (1993). A meta-analysis of Pardeck, J. T. (1991). Using books in clinical practice.
self-help treatment approaches. Clinical Psychology Re- Psychotherapy in Private Practice, 9, 105±115.
view, 13, 169±186. Peck, M. S. (1978). The road less traveled. New York:
Gould, R. A., & Clum, G. A. (1995). Self-help plus minimal Simon & Schuster.
therapist contact in the treatment of panic disorder: A Persons, J. B. (1997). Dissemination of effective methods:
replication and extension. Behavior Therapy, 26, Behavior therapy's next challenge. Behavior Therapy, 28,
533±546. 465±471.
Gould, R. A., Clum, G. A., & Shapiro, D. (1993). The use Prather, H. (1970). Notes to myself: My struggle to become
of bibliotherapy in the treatment of panic: A preliminary a person. Moab, UT: Real People Press.
investigation. Behavior Therapy, 24, 241±252. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C.
Greenberger, D., & Padesky, C. A. (1995). Mind over mood: (1992). In search of how people change: Applications to
Change how you feel by changing the way you think. New addictive behaviors. American Psychologist, 47,
York: Guilford. 1102±1114.
Halliday, G. (1991). Psychological self-help books: How Quakenbush, R. L. (1991). The prescription of self-help
dangerous are they? Psychotherapy, 28, 678±680. books by psychologists: A bibliography of selected
Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental bibliotherapy resources. Psychotherapy, 28, 671±677.
illness: Stress, coping, and adaptation. New York: Rachman, S., & de Silva, P. (1996). Panic disorder: The
Guilford. facts. Oxford, UK: Oxford University Press.
Hayes, S. C., Jacobson, N. S., Follette, V. M., & Dougher, Rosen, G. M. (1987). Self-help treatment books and the
M. J. (Eds.) (1994). Acceptance and change: Content and commercialization of psychotherapy. American Psychol-
context in psychotherapy. Reno, NV: Context Press. ogist, 42, 46±51.
Heather, N., Robertson, I., MacPherson, B., Allsop, S., & Santrock, J. W., Minnett, A. M., & Campbell, B. D. (1994).
Fulton, A. (1987). Effectiveness of a controlled drinking The authoritative guide to self-help books. New York:
self-help manual: One-year follow-up results. British Guilford.
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Hester, R. K., & Delaney, H. D. (1997). Behavioral self- Efficacy of self-administered treatment programs: Meta-
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65, 686±693. follow-up of the effects of bibliotherapy for depressed
Kazdin, A. E., & Krause, R. (1983). The impact of older adults: Journal of Consulting & Clinical Psychology,
variations in treatment rationales on expectancies for 58, 665±667.
therapeutic change. Behavior Therapy, 14, 657±671. Scogin, F., Jamison, C., & Gochneaur, K. (1989).
Lewinsohn, P. M., Munoz, R. F., Youngren, M. A., & Comparative efficacy of cognitive and behavioral bib-
Zeiss, A. (1992). Control your depression. New York: liotherapy for mildly and moderately depressed older
Simon & Schuster. adults. Journal of Consulting & Clinical Psychology, 57,
Lidren, D. M., Watkins, P. L., Gould, R. A., Clum, G. A., 403±407.
Asterino, M. & Tulloch, H. L. (1994). A comparison of Seligman, M. E. P. (1994). What you can change and what
bibliotherapy and group therapy in the treatment of you can't: The complete guide to successful self-improve-
panic disorder. Journal of Consulting & Clinical Psychol- ment. New York: Alfred A. Knopf.
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Linehan, M. M. (1993). Cognitive-behavioral treatment of (1997). Three-year followup of bibliotherapy for depres-
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Mahalik, J. R., & Kivlighan, Jr., D. M. (1988). Self-help 324±327.
treatment for depression: Who succeeeds? Journal of Sobell, M. B., & Sobell, L. C. (1993). Problem drinkers:
Counseling Psychology, 35, 237±242. Guided self-change treatment. New York: Guilford.
Mahoney, M. (1988). Beyond the self-help polemics. Starker, S. (1986). Promises and prescriptions: Self-help
American Psychologist, 43, 598±599. books in mental health and medicine. American Journal
Marrs, R. W. (1995). A meta-analysis of bibliotherapy of Health Promotion, 1, 19±24, 68.
studies. American Journal of Community Psychology, 23, Starker, S. (1988). Do-it-yourself therapy: The prescription
843±870. of self-help books by psychologists. Psychotherapy, 25,
Marx, J. A., Gyorky, Z. K., Royalty, G. M., & Stern, T. E. 142±146.
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ness of bibliotherapy, individual and group self-control Help for obsessive-compulsives. Oakland, CA: New
training in the treatment of problem drinkers. Addictive Harbinger.
Behaviors, 5, 13±24. Stiles, W. B., Shapiro, D. A., & Elliot, R. (1986). Are all
Mueser, K. T., & Glynn, S. M. (1995). Behavioral family psychotherapies equivalent? American Psychologist, 41,
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Methods for enhancing motivation to change. Cognitive New York: Random House.
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Ogles, B. M., Lambert, M. J., & Craig, D. E. (1991). practice. Behavior Research & Therapy, 35, 205±210.
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Expectations and attributions. Journal of Counseling treatment of unipolar depression: A comparison of
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6.13
Preventive Goals and Indirect/
Consultation Strategies: Meeting
Current Needs Through a
Recommitment to Underused
Means and Ends
RAYMOND P. LORION
Ohio University, Athens, OH, USA

6.13.2 ANTECEDENTS TO PREVENTIVE CONSULTATION/INDIRECT STRATEGIES 280
6.13.3 BEFORE THE BEGINNING; RETRACING PAST STEPS 282
6.13.4 THE COMMUNITY MENTAL HEALTH MOVEMENT: A LOST OPPORTUNITY 283
6.13.4.1 Shifting One's Conceptual Frame 284
6.13.4.2 Shifting Emphasis from Inside to Outside 287
6.13.5 EXTERNALIZING THE STUDY OF BEHAVIOR 288
6.13.6 ENVIRONMENTAL MODELS OF BEHAVIOR 289
6.13.7 TRANSACTIONAL MODELS OF BEHAVIOR 290
6.13.7.1 Linking Inside and Outside 291
6.13.8 SHIFTING TO A PREVENTION FOCUS 293
6.13.9 MERGING INDIRECT/CONSULTATION STRATEGIES WITH PREVENTION GOALS 294
6.13.10 FINAL COMMENT 297
6.13.1 INTRODUCTION related assumptions. First, information will

increase the acceptance and delivery of the
Chapters encouraging the adoption of alter- proposed alternative. Second, existing resis-
native approaches to service delivery typically tance to application of these services reflects a
combine an overview of intervention strategies lack of information. Third, information about
with a critical review of evidence for or against these has been developed in spite of resistance.
each strategy. Such an approach reflects several Fourth, information developed for strategies
277
278 Preventive Goals and Indirect/Consultation Strategies
which have typically been limited to highly necessary components of a comprehensive

controlled use will be accepted as relevant to the mental health and health care strategy. See-
decision to incorporate these approaches into mingly, such was also the case for the
existing service delivery strategies. Finally, with unfortunate de-emphasis of indirect/consulta-
sufficient evidence, the existing service delivery tion strategies following their most recent
strategies may be replaced by the alternative introduction. At the same time, currently
approaches. existing and expected conditions are likely to
An alternative perspective is that understand- alter the perceived importance of these very
ing resistance to changing current services and strategies.
professional definitions is an essential first step Originally focused solely on ªindirect/con-
to achieving such changes. The transition of sultation strategies,º the chapter took an
mental health from direct to indirect services and unexpected and fortuitous turn. The invitation
from a clinical treatment model to a public to prepare the chapter for this set of volumes
health prevention model has been understand- came as somewhat of a surprise to the author.
ably slow and difficult. This chapter reflects Although involved with the development,
the belief that such transitions are necessarily implementation, and evaluation of community-
and appropriately slow and that professional based mental health interventions for nearly a
resistance is best understood as natural and quarter century, I had not associated my work
well-intended rather than as selfish and mean- on the prevention of emotional and behavioral
spirited. Rather than look for enemies to disorders with ªindirect/consultative ap-
progress, one must understand its impediments proaches.º On reflection, the link is as obvious
and plan accordingly. Such is the focus of this as it is appropriate. Preventive interventions, by
chapter which reviews the history, conceptual, definition, focus on antecedents and concomi-
and practical obstacles to the widespread tants of dysfunction rather than on dysfunction
acceptance, development, and implementation itself. As such, they both represent and rely
of indirect/consultation and preventive ap- heavily on indirect means of responding to
proaches by the mental health professions mental health needs. Conceptually, their influ-
generally and clinical psychology specifically. ence depends on understanding the nature and
Rather than attempt to present a compendium dynamic processes among individual and situa-
of strategies of questionable scientific merit and tional factors which are salient to pathogenesis
pragmatically uncertain dissemination, I will (Lorion, Price, & Eaton, 1989). Pragmatically,
examine the circumstances under which pro- the intervention's target is not the pathology but
gress had developed thus far and propose its antecedents, that is, enabling circumstances
avenues for accelerating the pace at which and related individual diatheses.
further development occurs. A second reason for the surprise was that
Admittedly, the chapter focuses on the contemporary interest in consultation and
development of these strategies in the US. indirect strategies was quite unexpected given
Systematic descriptions of how these strategies the nation's seeming abandonment of both the
have evolved internationally (e.g., in South goals and means of the community mental
America, Australia, and Europe) are being health movement born in the 1960s. The few
prepared for publication in 1999 and 2000 in the remaining vestiges of what was to be a ªbold
Journal of Community Psychology. new approachº for responding to the nation's
In his book, The creation of settings and the mental health needs seemed doomed in the
future societies, Sarason (1972) posits that to current environment of managed care, welfare
understand a human service one must examine reform, and the search for the origins of
the circumstances under which it is developed emotional and behavioral impairment through
and delivered. One must particularly appreciate neuroscience, genetic mapping, and research on
those pre-existing conditions which Sarason biopsychosocial models of development (e.g.,
(1972, p. 24) labeled as occurring during the Bronfenbrenner, 1979). Four decades after
period ªbefore the beginning.º Change as beginning with lofty goals and expectations,
reflected in an ªinnovativeº service, for exam- the community mental health center system
ple, does not arise without antecedents! Rather, appears but a skeleton of its former self.
it represents a sequence of events (some of which Whether even the skeleton will remain in the
can be identified and some of which cannot) next decade seems uncertain.
leading to recognition of the need for change Ironically, what may remain of the ªbold new
and of the form(s) which that change must take approachº is the seemingly least emphasized
to be accepted and incorporated within the and least valued of the five original mandatory
surrounding service structure. As explained in services, that is, consultation and education.
this chapter, such is the case for the growing Again, on reflection, the timeliness of these
recognition of preventive interventions as approaches is understandable. If emotional and
Introduction 279
behavioral problems are to be economically and these very activities, as professionals, deter-
efficiently addressed, they must be confronted mined, in part at least, their original career
early and on as many fronts as possible. choice. Understandably, therefore, their initial
Consultation and indirect strategies provide forays into consultation and education efforts
potentially cost-effective avenues for encircling reflected contemporary assumptions about the
situational and systemic elements of dysfunc- nature of disorder and established intervention
tion and thereby the potential for accelerating practices arising from such assumptions.
its amelioration. Less recognized, however, is The implementation of the remaining and
that these strategies might also contribute to a predominant mandatory elements of the com-
most timely goal, that is, the actual avoidance of munity mental health movement (i.e., outpatient
dysfunction. In effect, these strategies represent and inpatient services) focused primarily on
routes to the prevention of mental disorder and pathology as figure and the expert/therapist/
to the promotion of optimal development and provider-serving-the-learner/client/recipient-ex-
improved quality of life. change as ground. Within this framework,
The latter point highlights a link which has consultation and indirect/educational services
heretofore been largely ignored but which is were designed substantively and procedurally to
particularly salient to this chapter. The im- maximize the recognition of disorder, the
portance of indirect/consultation approaches efficiency and timeliness of referral for treat-
was acknowledged nearly four decades ago in ment, and the appropriate utilization of
President Kennedy's landmark message to the community-based resources for supporting the
nation calling for a ªbold new approachº for effects of intervention. As explained below,
responding to mental disorders: social legislation of the 1960s and 1970s
presented significant opportunities for the
. . . We must seek out the causes of mental illness mental health system and mental health profes-
and mental retardation and eradicate them. Here, sions to change their conceptions of problems
more than in any other area, ªan ounce of and solutions. Few (e.g., Levine & Perkins, 1997;
prevention is worth more than a pound or cure.º Mrazek & Haggerty, 1994; Sarason, 1981)
For prevention is far more desirable for all believe that the opportunities were taken or
concerned. It is far more economical and far more their potential fulfilled. Current and anticipated
likely to be successful. Prevention will require both
selected specific programs directed especially at
revisions of health and mental health care
known causes, and the general strengthening of policies present another chance for substantive
our fundamental community, social welfare, and change. Whether the outcome will differ re-
educational programs which can do much to mains, for now, uncertain. What is certain,
eliminate or correct the harsh environmental however, is that prior efforts at change were
conditions which often are associated with mental sincere but insufficiently cognizant of how
retardation and mental illness. (Kennedy, 1963, established practices, perspectives, and assump-
reported in Bloom, 1977, p. 264) tions about the nature of problems and solutions
shaped the likelihood of true innovation. As we
To pursue this goal, ªconsultation services to enter yet another era in which change is
other community agencies and mental health seemingly pursued, we must reflect on how
information and educationº (Bloom, 1977, p. current stances will necessarily shape our future.
267) were included as mandatory components What seems quite certain is that the potential
of community mental health services. The link for change which arose in the 1960s remains
between indirect/consultation strategies and unfulfilled! ªCommunityº in the community
preventive interventions was reaffirmed when mental health movement, for example, referred
the editors of this work extended the chapter's primarily to the recipient and the location of
focus to include all three strategies. services rather than to the rationale for and
Confronting the responsibility for designing procedures of those services (Bloom, 1984). For
and delivering a new array of services (i.e., this and other reasons, the heuristic and
partial hospitalization, emergency, consulta- programmatic importance of the link between
tion, and education) to heretofore underserved prevention as goal and consultation/indirect
segments (e.g., rural, low-income, or minority) strategies as means lost its immediacy. Also
of the population in unfamiliar settings (e.g., in clouded was appreciation of the vast array of
sparsely populated villages, inner-city ghettoes, alternatives which would have become available
or working-class neighborhoods), community had the focus been on health and its main-
mental health service providers initially focused tenance rather than on pathology and its
on established and evident need rather than treatment or control. Ideally, this chapter will
incipient or potential disorder (Bloom, 1975; focus attention on the potential of those links
Cowen, 1973). As clinicians they were trained to and result in a broadening of perspectives as
recognize and treat disorder. Interest in doing contemporary health and mental health service
providers design intervention systems for the epidemiological analyses of mental illnesses.
future. Toward that goal, it is important to note In addition to publication of numerous mono-
that the community mental health movement graphs reporting the results of individual
represented a return to rather than discovery of studies, the Joint Commission (1961) submitted
the value of indirect/consultation strategies. an integrative summary of its findings and
That recognition occurred decades before! In recommendations in its final report entitled
fact, the link between indirect strategies and Action for mental health. That report provided
prevention was unquestioned in the early the substantive foundation for the Community
twentieth century! Mental Health Centers Act of 1963.
The Joint Commission's report was sup-
6.13.2 ANTECEDENTS TO PREVENTIVE ported by two significant epidemiological
CONSULTATION/INDIRECT studies (Hollingshead & Redlich, 1958; Srole,
STRATEGIES Langner, Michael, Opler, & Rennie, 1962)
published during that period. Whether mea-
Legislative initiatives have understandably sured in terms of need or demand for services, a
been assigned as much if not more of the credit serious imbalance was evident between the
than scientific findings and professional interest availability of mental health services and the
for moving to center stage the mental health prevalence of mental disorder in adults. A
disciplines' recognition of and involvement with subsequent epidemiological study confirmed
prevention and indirect/consultation strategies. the existence of at least an equivalent imbalance
Attention to indirect/consultation strategies, for between children's needs and available services
example, is assumed to have resulted from (Glidewell & Swallow, 1969). These and related
passage of the Community Mental Health studies provided what appeared to be convin-
Center Act (Public Law 88-164) of 1963. cing support of ªAlbee's (1959) pessimistic
Legislative antecedents to that Act included assessment that sufficient mental health staffing
the National Mental Health Act (Public Law 79- resources would never be available to treat those
487) of 1946. This law was written to facilitate in need within the dominant individual service
the incorporation of public health principles delivery models.
into the design and delivery of mental health Other sources of personnel (e.g., paraprofes-
services. It also authorized the establishment of sionals, Durlak, 1979, and ªnatural care givers,º
the National Institute of Mental Health which Cowen, 1982) and other models of service (e.g.,
included the prevention of mental disorder empowerment strategies, Rappaport, 1977) if
among its stated purposes. More than a decade developed and supported offered routes to
would pass, however, before that goal was redressing these imbalances. The founders of
publically acknowledged. Nearly two more the emerging field of community psychology and
decades would pass before substantive action their followers devoted considerable effort to
was taken to achieve this goal (Goldston, 1986). pursuing such alternatives (Cowen, Gardner, &
Nearly 50 years after passage of Public Law 79- Zax, 1967; Iscoe, Bloom, & Spielberger, 1977).
487, preventive intervention research remains in Although overlapping in terms of their goals and
the early stages of development and the objectives, community psychology (e.g., Heller,
products of its efforts, although increasing in Price, Reinharz, Riger, & Wandersman, 1984;
number and documented value, account for a Rappaport, 1977) and community mental health
very small portion of the nation's mental health (Bloom, 1984) took somewhat differing routes to
service effort (Durlak & Wells, 1997; Mrazek & finding alternative solutions to resolving the
Haggerty, 1994). needs/services imbalance. Each, however, em-
Further legislative actions fueled the potential phasized the development and dissemination of
for momentum in establishing and disseminat- preventive interventions and indirect/consulta-
ing indirect/consultation strategies. The Mental tion strategies as outcomes to be achieved. Each
Health Study Act (Public Law 84-182) of 1955 spoke of the value of expanding definitions of
created the Joint Commission on Mental Illness providers of service, of the timing of services, and
and Health charged with conducting a thorough of the nature of services (Riessman, 1965). Both
and objective study of the human and economic community psychology and community mental
costs of the nation's mental health needs, health, however, retained a strong identification
services, and service delivery systems. The Joint with clinical psychology. With notably few
Commission took this assignment seriously. exceptions (Iscoe et al., 1977; Phares & Trull,
Over five years, it conducted comprehensive 1997), doctoral programs in these emerging
studies of topics ranging from the adequacy of fields devoted far more time to training in
staffing resources (Albee, 1959) to public traditional theories of pathology and traditional
attitudes toward mental health needs and methods of diagnosis and treatment than in
services (Gurin, Veroff, & Feld, 1960) to those uniquely distinct theories and methods
Antecedents to Preventive Consultation/Indirect Strategies 281
focused on communities. Understandably, pro- traditional diagnostic and therapeutic services

fessional identification was more likely to (Phares & Trull, 1997). The inclusion of
default to clinical than community psychology. reimbursement for mental health services in
Simultaneously, prevention's advocates re- health care policies and the growing public
minded policymakers of the public health acceptance of outpatient mental health services
maxim that no disease or disorder had ever led, in psychology, to a proliferation of
been controlled by treatment but only by university and nonuniversity-based programs
prevention. As early as 1962, the American for health service providers (Phares & Trull,
Public Health Association identified six cate- 1997). The shortages in mental health profes-
gories of mental disorder which, because their sionals capable of serving individual needs
etiology was known, were preventable (Bloom, predicted by Albee (1959) appears to have been
1984). These categories included diseases caused substantially resolved, if not replaced by a
by: (i) poisons (e.g., brain syndromes following surplus (Routh, 1998).
exposure to solvents); (ii) infections (e.g., The surplus becomes undeniable if subdoc-
rubella); (iii) genetic disorders (e.g., TAY- toral providers in psychology, counselor educa-
SACHS disease); (iv) nutritional deficiencies tion, marital and family practice, counselor
(e.g., pellagra); (v) injuries (e.g., traumatic head education, nursing, and social work are in-
injuries); and (vi) general systemic disease (e.g., cluded in service delivery resources.
prematurity). It is important, however, to note Ignored in this solution were the alternatives
that early in the development of the community suggested by Albee (1959) and echoed in the
mental health movement, prevention repre- Community Mental Centers Act, that is, to
sented not simply an idea but also an attainable expand the range of personnel available to
goal. Moreover, guidelines for shifting to provide services and to expand the range and
alternative approaches were provided by Ca- nature of those services. Indirect/consultation
plan in his influential works, Principles of efforts targeted at other than the detection of
preventive psychiatry (1964) and The theory those in need of referral for treatment or the
and practice of mental health consultation (1970). enhancement of nonmental health service
Riessman (1965) among others (e.g., Fair- providers (e.g., teachers, social service case
weather, Sanders, Maynard, & Cressler, 1969) workers) to support mental health interventions
described innovative ways in which self-help could not be justified within the prevailing
and environmental change, alone or in combi- understandings of pathogenesis, dysfunction,
nation, offered relief which could precede and and treatment. Similarly, efforts to establish the
potentially avoid dysfunction and exacerbation feasibility of responding to mental health needs
of existing problems. These efforts did not using providers who were indigenous to the
depend on professional resources to operate communities in which the problems arose (e.g.,
and, under appropriate circumstances, may Sobey, 1970) may have demonstrated their
have become self-sustaining. effectiveness (e.g., Dawes, 1994; Durlak, 1979)
Yet the solution to a problem is determined in but the weight of evidence was insufficient to
large part by how it is defined and how it is topple the individual focus and internal em-
presumed to have arisen. As noted, the move- phases dominant at the time.
ment toward community-based service delivery Being from the neighborhood, for example,
occurred at a time that conceptions of health could only be of advantage to a service provider
and especially pathology were focused primarily if characteristics of the neighborhood were
on internal individual states (Sarason, 1981). assumed to contribute to the etiology, main-
Changes in the individual's affective response to tenance, and resolution of emotional and
stress, behavioral response to external stimuli, behavioral dysfunction. If one assumed other-
and the capacity to alter those responses were wise, one would reasonably question the
assumed to occur through interventions tar- therapeutic benefit of attracting and retaining
geted to individuals. From that perspective, a heretofore untreated segments of the popula-
reasonable response to Albee's (1959) prediction if the insights needed for symptom removal
tion of chronic shortages in mental health could not be achieved in the presence of an
professionals capable of delivering individual ªunqualified therapist.º Those who challenged
services was to resolve that shortage by the innovativeness of the community movement
increasing the nation's capacity to train such pointed to its seeming lack of theory and focus.
professionals. Concurrent with legislation to Levine and Perkins (1997) describe reactions to
incorporate public health concepts into mental the community mental health movement as
health theory and practice and to establish the follows:
community mental health movement, Congress
funded programs to train substantial numbers The new thrust went off in all directions at once,
of mental health professionals to provide with little coherence and little conceptual clarity.
Critics committed to traditional medical model 6.13.3 BEFORE THE BEGINNING;

practice looked askance at social activism. Those RETRACING PAST STEPS
committed to ªintrapsychic supremacy º (Levine,
1969)Ðthe belief that problems in living result Examination of the scientific and legislative
from people's internal psychological structures,
which in turn dictate perceptions, feelings, and
accomplishments reviewed thus far might lead
actions in everyday situationsÐviewed the acti- one to conclude erroneously that prevention and
vists as misguided romantics who had foolishly indirect/consultation strategies were neither
strayed from proper professional roles and activ- recognized nor attempted before the latter half
ities. Community-oriented critics of traditional of the twentieth century. The legislative initia-
practice were equally firm in their convictions tives and epidemiological studies just described,
but had little to offer by way of alternate con- however, were not mental health's initial foray
ceptualizations. (pp. 59±60) into indirect/consultation and preventive stra-
tegies. Human services generally and the mental
Alternative perspectives had yet another health services specifically have not only applied
chance to establish themselves as a viable such strategies throughout the twentieth century
element of federal health care policies. Shortly but periodically such strategies represented a
after his election, President Carter created the dominant and explicit objective. Considered in
President's Commission on Mental Health to their entirety, it appears quite possible that
review the state of the nation's needs and indirect/consultative approaches and even pre-
response capacity. In essence, the Commission's ventive interventions may have both a longer
numerous task forces and panels revisited the and a more successful history than interventions
issues raised by President Kennedy's group and which provide direct services to individuals.
recommended continued and vigorous pursuit In their analysis of the history of consulta-
of many of its most innovative elements. The tion, for example, Mannino and Shore (1986)
Commission's findings were translated into the report that clinical psychology has been asso-
Mental Health Systems Act (Public Law 96- ciated with such interventions since its incep-
398). Included within this legislation was the tion. Long identified as a defining milestone of
requirement that the National Institute of clinical psychology's formation as a profession,
Mental Health establish an administrative unit the establishment of Lightner Witmer's psycho-
focused on funding, evaluating, and disseminat- logical services clinic at the University of
ing preventive interventions. The prevention of Pennsylvania in 1896 is also quite relevant to
emotional and behavioral disorders was to this chapter. Reportedly, this clinic's services
become a central and adequately supported documented early professional appreciation of
element of the nation's mental health policy the value of indirect services and of both the
(Bloom, 1984). Significant changes in service desirability and feasibility of balancing atten-
and training priorities were expected along with tion to referred needs with creation of ways to
consequent shifts in the balance of direct and avoid such needs (Mannino & Shore, 1986).
indirect approaches to serving the nation's Little known is the fact that Witmer's clinic
mental health needs. Just as suddenly, the relied on consultative interventions to deliver a
Mental Health Systems Act was repealed! substantial portion of its services. Comprehen-
Newly elected President Reagan's initial budget sive assessments of the nature and origins of
shifted to the states responsibility for deciding children's cognitive, behavioral, and impulse
which services to provide with the federal control problems were, for example, as likely to
government's newly designed block-grant fund- result in interventions with the child's family or
ing approach to underwriting the costs of such school as with the child. Frequently, analysis of
services. If they were to be funded, the pre- the needs of a referred child included diagnostic
ventive and indirect services needed to compete assessments of instructional procedures. In
for limited funds which were primarily used to turn, the intervention often involved prescrip-
support the provision of direct services to those tive changes in school curriculum and detailed
with established diagnosed needs. Unfortu- suggestions to teachers for handling disruptive
nately, the promises of benefits to be gained behavior within the classroom setting.
from support for preventive interventions sig- Established during the initial decade of the
nificantly exceeded the evidence of such benefits twentieth century to respond to the needs of
(Lorion et al., 1989; Mrazek & Haggerty, 1994) immigrants and low-income families, the Settle-
and left the field open to significant challenge ment House Movement hired teachers to visit the
(Albee, 1986). Ironically, an appreciation of the schools enrolling the children of families served
history of mental health strategies would have by the Movement. These itinerant teachers
revealed that justification for these alternative would observe classroom procedures and re-
services could be found in the efforts of mental commend changes in curriculum, classroom
health providers decades earlier. organization, and instructional methods to
The Community Mental Health Movement: A Lost Opportunity 283
improve children's educational performance. organization, the goal was not to change it into
Such visits were intended both to reduce the a mental health agency but to improve the
needs of identified children and to enhance the developmental sensitivity, efficiency, and effec-
overall effectiveness of the classroom. Without tiveness of its intended services.
being labeled as such, these visits represent very Reflecting on these approaches, it becomes
early attempts to prevent emotional and beha- apparent that attention to indirect/consultation
vioral problems and to promote optimal devel- strategies preceded by several decades the
opment and adaptive functioning. community mental health movement. Lessons
In the 1920s, similar goals were pursued by the reflected in these services included appreciation
Child Guidance Movement. Healy's Juvenile of the need to understand, value, and respect the
Psychopathic Institute in Chicago, for example, perspectives and skills of a variety of service
developed and implemented programs to assist organizations. Movements developed at the
troubled youth by enhancing the capacity of turn of the twentieth century (e.g., Child
relevant community agencies, including the Guidance, Settlement Houses, Mental Hygiene)
schools, to serve the needs of referred and appreciated the significant problems in adjust-
nonreferred youth. Healy's staff also worked to ment confronting families attempting to cope
increase public understanding of mental health with immigration, emigration, and poverty.
principles and public acceptance of emotional Neither the families nor the organizations
problems. The recipients of these educational associated with these movements had adequate
programs were the communities in which the resources; both confronted challenging and
youth lived and the public agencies which served unforgiving circumstances. Early on, the move-
them. Child Guidance staff in other cities ments recognized that attempting to solve
established service priorities for a community problems individually could not succeed. With
based on systematic assessments of local needs their limited financial and staff resources, they
and resources. Findings from this planning step focused on reducing the demanding quality of
identified gaps in services and achievable the environment, on enhancing the responsive-
objectives. Problem solutions often included ness of existing organizations, and the benefits
programs to educate staff from relevant agencies of interorganizational collaboration and (long
about mental health principles and strategies. before the term was popular) on empowering
Child Guidance staff also worked to improve parents, teachers, and citizens to respond to
a community's readiness to develop its own needs confronting them.
child guidance capacity. As described by
Mannino and Shore (1986), such capacity
development activities included the aforemen- 6.13.4 THE COMMUNITY MENTAL
tioned local assessments as well as field services HEALTH MOVEMENT: A LOST
which carried out site visits, assisted existing OPPORTUNITY
service organizations to recognize the contribu-
tions of other human services, and identified As noted, following an intensive study of the
ways for these organizations to network and nation's mental health needs and resources, the
collaborate. Through their activities, child Joint Commission on Mental Health and Illness
guidance workers sought to make explicit the concluded that a ªbold new approachº was
close relationship between the child and family needed if services were to respond to need (Joint
as case and the community in which services Commission on Mental Health and Illness,
were provided. Aware of the futility of 1961). The Joint Commission's report urged the
attempting to respond individually to each nation to pursue alternatives to a mental health
case, child guidance workers often chose instead delivery system which was recognized as un-
to alter the settings (e.g., home, school) in which available, inaccessible, and unacceptable to
the child lived and learned by influencing the significant portions of the population (Joint
decisions made by teachers, parents, and other Commission on Mental Health and Illness,
caretakers. To effect such changes, caretakers 1961). Then as now, the need for responsiveness
were provided information about human devel- and relevance mandated the development of
opment and child care methods. Child guidance strategies which fit the actual circumstances
workers explained these principles and provided within which people lived, learned, worked, and
direct models of alternative parenting or recreated. Then as now, the need to respond
teaching behaviors. Child guidance workers early rather than later was perceived as both
recognized that their consultative and educa- economically responsible and humane. Then as
tional services should not be designed to make now, responsibility for the emotional and
their recipients into mental health workers but behavioral health of individuals extended be-
rather to improve their functioning as parents or yond the mental health professions. As reported
teachers. When the recipient was a service by Gurin et al. (1960), physicians and the clergy
were considerably more likely than psycholo- four sessions required for inclusion in the study.
gists, psychiatrists, or social workers to be For a moment after I entered on this day, the
approached for help with emotional problems. waiting room full of therapy clients confirmed
Subsequently, Cowen (1982) noted that hair- my certainty that our protocol represented a
dressers, bartenders, retired persons, and many solution to the unacceptable levels of measured
others in the community served or could serve as pathology in low-income populations (Lorion,
valuable resources for those experiencing emo- 1973, 1974).
tional discomfort. Suddenly, I realized that however successful
What in the past may have been defined as we were, the room would never empty! Clients
ªsimply being a good neighborº has the potential would come and go; their improvement ranging
of being organized into a pervasive network of from considerable to none. Yet, without a
support for those suffering distress which can be substantive change in the system of care, others
tapped naturally without risking the personal would always take the place of those who left.
and public stigma of mental health diagnosis and This prediction appeared valid whether long- or
treatment. Many forms of indirect/consultation short-term interventions were provided and
approaches are, in fact, designed to sensitize whether the recipients were individuals, groups,
others to the responsibility and ease of ªsimply or families. To empty the waiting room, I and my
being a good neighborº and to facilitate their colleagues would have to change our sense of
capacity to fulfill it. Regrettably, these ap- when, where, and how we intervened. We would
proaches received far too little attention to also have to shift our definition of the problem
flourish during and since the 1960s. In fact, few and of our responsibility for its solution from the
ªbold new approachesº were developed which waiting room to the circumstances and condi-
redefined the timing and nature of mental health tions which led to its need. We would, in effect,
interventions. The question presented in this have to shift our existing theories of how
chapter is: ªwill the potential of indirect/ problems arose and our theories of their
consultation be recognized and exploited now solutions. Such shifts presented enormous
and in the decades to come?º challenges to a system seemingly committed to
One by one, whether labeled client, patient, or change. As noted, our profession has yet to
consultee, those presenting emotional and commit wholeheartedly to confronting those
behavioral dysfunction have been approached challenges!
by growing legions of mental health service
providers. The sincere and somewhat effective
efforts of these providers have not, however, 6.13.4.1 Shifting One's Conceptual Frame
stemmed the tide. As reported in Rouse (1995),
the proportion of the nation's citizens suffering With hindsight, it seems difficult to under-
from emotional and behavioral (including stand the mental health fields' reluctance to
substance abuse) disorders remains unaccepta- adopt wholeheartedly the flexibility and poten-
bly high. Nor is there any basis for anticipating tial breadth of effect associated with applying
this tide to abate in the foreseeable future. indirect/consultation strategies in the pursuit of
Whatever their modality, direct approaches are preventing mental illness and responding to
limited in this regard by their focus on the emotional disorders. Passage of the Community
individual and by the requirement that pathol- Mental Health Center's Act provided the
ogy must be present or imminent before political support and financial backing see-
intervention can take place. mingly necessary for shifting from an emphasis
In his pointedly titled book, The absurd healer, on treatment to understanding and ultimately
Dumont (1968) foresaw this outcome as the controlling factors relevant to the development
community mental health movement was just and maintenance of disorder. Bloom's (1977)
beginning. A decade later, I experienced Du- analysis of this ªbold new approachº makes
mont's insightful moment as I entered the evident that talented, dedicated, and hard
waiting room of a public clinic. I was then part working individuals were committed to its
of a team of mental health professionals excited development. Soon after passage of this land-
by the opportunity to develop a short-term mark legislation, the Swampscott Conference
therapy program for indigent clients. We seemed laid the foundation for the field of community
to be a success! Clients were referred in psychology (Bennett et al., 1966). Subsequent
substantial numbers; most cooperated with organizational meetings of this group (e.g.,
treatment protocols and participated in the Iscoe et al., 1977) gave evidence that this
8±10 session program. We gloated to colleagues emerging field had momentum as reflected in
when an attempted comparison with long-term budding programs of research, the development
protocols could not be completed because few of of programs at the master's and doctoral levels,
the long-term clients attended the minimum of and a growing corps of adherents anxious to
enlist in this movement. Voicing a commitment indirect strategies early in the twentieth century
to the integration of science and practice, this make evident that their limited survival cannot
emerging field's established leaders led the way be attributed to a lack of talent in its advocates,
for successive generations to establish a critical a lack of social support for the resulting
mass of providers of indirect/consultation and programs, or even a lack of evidence of their
preventive interventions (Iscoe et al., 1977). contribution to the welfare of those served. It is
Within a decade of its inception, community seemingly not about the creativity of those who
psychology appeared to have the commitment, design interventions, the importance of the
momentum, and tools to move mental health research questions raised, the social problems
toward acceptance of conceptions of etiology addressed, or the explanatory power of the
that extended beyond the individual and con- methods used to find answers (Sarason, 1996).
ceptions of intervention that redefined service Having devoted much of his career to
delivery in partnership (Tyler, Pargament, & understanding the intractability of educational
Gatz, 1983) rather than caretaker roles (e.g., methods to genuine change, Sarason (1990,
Heller & Monahan, 1977; Levine & Perkins, 1993) warns against attempts to understand the
1997; Rappaport, 1977). After a decade of intransigence of existing approaches by finding
building a foundation for a national program of and blaming those who oppose change. He
prevention work (Klein & Goldston, 1977), this notes:
perspective shift appeared to have taken root
and become ready to blossom. For the next Our task would be incomparably easier if such
decade, leading advocates of prevention science, villains existed. Being imprisoned in tradition,
policy, and practice met regularly at the being resistant to and fearful of anything other
Vermont Conference on the Primary Prevention than superficial change and window dressing,
of Psychopathology (Kessler & Goldston, 1986). puzzled by the failure of past efforts, allergic to
Funding for research on the prevention of fads and fashions, disenchanted with quick fixesÐ
such attitudes and reactions are not those of
emotional and addictive disorders began to rise
villains. (Sarason, 1993, p.13)
with passage of the Community Mental Health
Centers Act in 1963, a trend which has generally
continued to the present (Mrazek & Haggerty, Subsequent comments about impediments to
1994). educational change seem equally applicable to
Yet, three decades after passage of the understanding the pace at which indirect/con-
Community Mental Health Centers Act and sultation and preventive approaches have been
five decades after formation of the National adopted by the mental health fields:
Institute of Mental Health with its mandate to
bring public health principles to mental health If everyone is in agreement that we are faced with a
care, the mental health fields remain at best set of problems that we have to do something
ambivalent toward and distant from prevention about, and if in the post-World War II era serious
people have committed themselves to valiant
as a goal and indirect/consultation strategies as efforts at reform, why have the results been either
means to that goal. Proposing recommitment to so modest, minuscule, or nonexistent? That was
that goal or attempting to convince readers that the question the book (Sarason, 1990) tried to
recent scientific findings argue convincingly illuminate. It was not about what to do; it was
that it lies within reach seem quite unlikely to about how we have been thinking, what axioms we
have other than limited success. Rather, it seems have unreflectively accepted as right, natural, and
important to examine the mental health field's proper, and alternative ways we should begin
seeming resistance to what all agree is a think. (Sarason, 1993, p. 13)
desirable outcome, that is, the avoidance of
disorder and the promotion of positive mental Sarason explains that existing conceptions of
health. Levine and Perkins (1997) raise a how emotional and behavior disorder devel-
plausible explanation, that is, those proposing oped and needed to be remedied were reflected
the shift from treatment to prevention and from in priorities for research and interventions.
direct to indirect/consultation services ªhad Assuming that the seeds of pathology lay within
little to offer by way of alternate theoretical the individual leads to the conclusion that
conceptualizationsº (p. 60). changes in the individual are necessary to
Other explanations seem rather less easily correct disorder. That perspective was domi-
supported. Resistance to changing mental nant before, during, and after earlier attempts
health's goals and methods must be considered to shift from direct to indirect approaches and
historically. As reported in Mannino and was reinforced by clinical psychology's accep-
Shore's (1986) review and echoed in Sarason's tance of psychiatry and medicine as the definers
autobiography (1988), we have been there of the nature of problems and solutions (Phares
before! Attempts to develop and disseminate & Trull, 1997; Sarason, 1981, 1985).
Reluctance to shift to the public health the organizational and psychotherapeutic lit-
perspective are understandable. Public health erature, it is that those who seek to change find
practitioners traditionally have viewed disease themselves at some point resisting changeº
and disorder as the consequence of complex (p. 28). His perceptions about the difficulty of
relationships between individual vulnerabilities creating new forms of service settings seem to
(i.e., diatheses) and situational factors (i.e., apply equally to the creation of alternative
stress) and of interventions (especially those services. Resistance to change must be recog-
seeking to prevent disorder) as requiring an nized and expected as part of the process of
understanding and alteration of aspects of the change which must be thoughtfully and sensi-
host (i.e., the individual presenting the dis- tively countered rather than simply regretted or
order), the agent (i.e., the cause of the disorder), condemned. Regarding the introduction of
or of the environment (i.e., of the circumstances innovative settings, Sarason appreciated that
which bring the host in contact with the agent) ªif there was anything about which we were
(Lilienfeld & Lilienfeld, 1980). Ideally, at least a truly secure on the basis of past experience, it
portion of the contributions of each element of was that we were embarking on a venture that
this classic public health triad (i.e., host, agent, was very complicated, guaranteed to arouse
environment) will be understood in planning the anxiety and doubt, and, in all respects a venture
preventive intervention. That understanding that could bring out the best and worst in usº
will identify those points along the etiological (Sarason, Zitnay, & Grossman, 1970, p. 71).
chain vulnerable to intervention and thus Reflecting on the fate of indirect/consultation
opportunities for avoiding or interrupting the and preventive approaches thus far, one might
pathogenic process. apply the same lesson.
The public health perspective challenges many Moving from an individual-clinical to a
core elements of clinical psychology's most public health perspective required abandoning
influential theories, research methods, and what was known and valued by the profession
concerns (e.g., to understand, predict, and and, admittedly, reimbursed by society. As
control individual differences). Not surprisingly, noted, the design, development, and delivery of
clinicians tend to focus their research and public health interventions ran (and continues
services at the individual level. By contrast, to run) counter to many aspects of clinical
public health interventions target populations or training. Many indirect/consultation and pre-
segments thereof and measure their impacts at ventive interventions are intended to preclude
the population rather than individual level. Of either the need for clinical intervention or for
concern to proponents of indirect/consultation professional intervention. In either case, clinical
and preventive approaches is the seeming involvement in mental health service delivery
reluctance of psychology's community-oriented would be reduced. The fact that, once estab-
fields to emphasize public health rather than lished, the majority of public health interven-
traditional clinical orientations. This individual tions would not even belong to us raises yet
orientation is confirmed in examinations of the another impediment to shifting from clinical to
content and methods of published community public health perspectives. Few professionals
psychology research in its initial decades (Louns- readily accede to such generosity! More likely
bury, Cook, Leader, & Mears, 1985) and we are influenced by ªprofessional precious-
thereafter (Heller, 1989; Levine & Perkins, ness,º that is,
1997). Community psychology's endorsement
of the prevention of disorder and the develop- the tendency of . . . professionals to view their
ment and adoption of interventions to change technical skills in very precious kinds of ways, that
social policies and resolve social inequities as is, to overestimate the differences in skills among
defining goals are slowly translating into sub- the professions and to underestimate the
stantial research and programmatic activity communalities . . . . Each field does have a core
of distinctiveness, and thus should be both recog-
beyond the individual level of analysis or impact.
nized and treasured. It is one thing, however, to say
Echoing Sarason (1993), I would assert that that each field has a distinctive core of skills and it
the villains who are obstructing our pursuit of is quite another thing to say that everything a
innovation and appreciation of indirect/con- particular profession does is either distinctive or
sultation and preventive approaches are not not, in part at least, learnable by the other
ªthemº; contrary to Pogo, nor are they us! The professions in the settings in which they work
impediment is the difficulty of leaving the together. (Sarason, Levine, Goldenberg, Cherlin,
traditions and methods of clinical training when & Bennett, 1966, p. 587)
such training is valued both within an existing
professional culture and within the larger If this applies to our dealings with other
society. Sarason (1993) argues that ªif we have professions, one can only assume it is not
learned anything with near certainty, both from diminished when those with whom we are to
share, if not turn over entirely, our clinical and circumstances under which they are displayed?
intervention skills are nonprofessionals. Were this the case, to what should one attend . . .
Consultants, after all, teach elements of their the people or the circumstances? Three decades
expertise to others so that those others can apply ago, as the Community Mental Health Move-
the elements. Health promotion and disease/ ment was getting underway, Barker (1968) and
disorder prevention involves us with segments his colleagues proposed that behavior settings
of the population to which we cannot lay claim have greater influence on the expression of
based on our expertise in the diagnosis and certain behaviors than the people who inhabit
treatment of psychopathology. Without an those settings. In other words, one might predict
accepted taxonomy of health, we cannot use a what will happen if one knows where it is
specialized lexicon to stake out that claim. expected to happen more so than if one knows
Indirect strategies which require entry into the who will be present. If generalizable, this
realm of public policy, system analysis, and assumption implies that understanding the
institutional change frequently requires that we conditions under which social services are
do so without a recognized credential which provided, classroom instruction is given, play
asserts prima facie that such involvement is both is attempted, or employment opportunities arise
our right and responsibility. Indirect/consulta- may predict expressed emotion and behavior
tion and prevention strategies demand that we better than (or if combined with) information
operate within alien territory in which generic about the individual's early childhood experi-
knowledge and skills are the currency for goal ences, measured intelligence, or personality
attainment. Encouraging people in need to take profile. It also implies that structuring those
advantage of self-help groups, enabling those conditions might influence predictably the
without such experience to recognize and assert experience and expression of emotions and
their right to influence the allocation of behaviors. Such a perspective would provide a
resources, and applying our science and profes- theoretical rationale for program, setting, or
sion to make teachers, parents and social service system consultation focusing on the conditions
providers better at what they do seem quite under which people lived, worked, played, and
discordant with established definitions of learned. Although given little attention, a
professional functioning. substantial theoretical and empirical basis for
In the sole course on consultation I encoun- responding to individual emotional and beha-
tered in graduate school nearly three decades ago vioral needs through indirect/consultation ap-
(during community psychology's presumed proaches has been developing for decades.
take-off phase), I was both impressed and It should be noted that attributions to factors
frightened to learn that effective consultation external to the individual have a long and
is documented by evidence that the service is no respected history in public health. The classic
longer needed by its recipient. It seemed that the ªhost±agent±environmentº model for under-
task required providing recipients of the services standing the occurrence of disease has success-
with possession of critical elements of what I fully informed efforts to prevent and control
offered to be shaped in whatever form they threats to physical health. It worked because it
deemed useful. My job, in effect, was to make my looked both within and outside the individual to
job unnecessary! Providing prevention and understand vulnerability and resistance to
indirect/consultation services seemed to require disease. Consideration of individual and envir-
literal acceptance of Miller's (1969) mandate onmental factors allows for the design and
that we ªgive psychology away.º It simulta- implementation of interventions whose health
neously challenged the content of most of my promotion or disease/disorder prevention ef-
didactic and clinical courses! It turned around fects can be delivered unobtrusively. To be
basic assumptions about professional responsi- effective, it is not necessary that the recipients of
bility, and about the patient's capacity to change these interventions be either identified or
their problem behaviors and feelings. Most participate actively. Rather, not unlike fluoride
importantly, perhaps, it required significant in the water or guard rails along the highway,
revision in the very understanding I was the environment can be changed in ways which
developing of why people behave and feel as are preventive and health promotive. Many of
they do. these interventions operate without profes-
sional involvement and independent of either
6.13.4.2 Shifting Emphasis from Inside to the cooperation or knowledge of the vulnerable
Outside individual. By contrast, the application and
ultimate success of treatment generally depend
Suppose that the emotions and behaviors on multiple patient variables including ac-
which concern mental health professionals knowledging the need for, having access to,
reflect not only internal processes but also the being able to pay for (in terms of money and
time), and complying with a treatment protocol. disproportionately occur. Alternatives to mias-
Interventions which have their effects indepen- ma were sought because of the variability of its
dent of such factors and, ideally, which preclude effects, that is, not all exposed became ill. Not
the need for treatment would clearly be understood at the time were how individual
logistically and humanly advantageous. To characteristics enhanced resistance or raised
consider those as viable, however, one must vulnerability. Such distinctions are central to
believe that factors external to the individual are contemporary diathesis-stress models of illness
salient to health and illness. (Lilienfeld & Lilienfeld, 1980). The complexity
In the early eighteenth century before germ of understanding how nonspecific setting fac-
theory accounted for contagion, the spread of tors mix with individual variability raises
disease among the poor was attributed to questions about the processes by which each
ªmiasmaº (i.e., bad air). As Bloom explained influences the other. More than six decades ago,
(1977): Lewin (1935) asserted the importance of con-
textual factors in his widely cited formula:
Miasma theory held that soil polluted with waste B = f(P, E)
products of any kind gave off a ªmiasmaº into the
air, which caused many major infectious diseases This formula reflects Lewin's (1944) concept of
of the day. People living near swamps, and thus ªpsychological ecology,º that is, consideration
particularly vulnerable to marsh gases, were of setting characteristics and opportunities and
thought to develop fever from these gasesÐa fever individual characteristics and constraints into
that came to be known as malaria (bad air). The predictions of human behavior. Lewin's per-
miasmist felt that the way to prevent disease was to
spective has been studied along the lines of
modify the environmentÐto remove the sources of
the miasma. (p. 71) research emphasizing, respectively, transac-
tional (i.e., the person in environment) and
environmental contributions to behavioral and
Given confirmation that a different external developmental processes. The distinction be-
factor,ªgermsº (i.e., viruses and bacteria) ex- tween the two lines of inquiry is one of relative
plained most infectious disorders, miasma the- rather than absolute emphases of the contribu-
ory had limited influence on public health policy tions of individual and situational factors in
and practice. Its major tenet, however, informs determining behavior. Both lines provide im-
concepts of vulnerability and resistance to portant scientific and clinical bases for the
emotional and behavioral disorders. design and evaluation of indirect/consultation
Miasma theory posits that nonspecific char- strategies and offer avenues for altering patho-
acteristics of an environment are pathogenic. genic processes toward preventive goals.
This position echoes widespread beliefs among The qualifier,ªtransactional,º represents an
mental health epidemiologists (e.g., Dohren- important element of Lewin's conceptualization
wend, B. P. & Dohrenwend, B.S., 1981; of behavioral dynamics. A transaction refers to
Dohrenwend, B. S. & Dohrenwend, B. P., the inter-relational processes between individual
1981; Dohrenwend et al., 1987) that elements of and situational factors in which each recipro-
the environment linked to experienced stress are cally influences the other. The distinction
significant pathogens. Analogously, it echoes between a ªtransactionº and an ªinteractionº
explanations of delinquency based on social lies in the former's bidirectional nature, that is,
learning and modeling processes (Berkowitz, each component in the transaction influences the
1993; Goldstein & Keller, 1987) and links successive states of the other. Dewey and Bentley
observed among neighborhood disorganiza- (1949) described transactional processes as a
tion, deterioration (e.g., the presence of broken basis for epistemological analysis. Based on the
windows and littered vacant lots), and antisocial models of thought articulated in that work, the
acts (Gold, 1987; Levine & Rosich, 1996). study of human behavior requires consideration
Continuing the analogy, indirect/consultation of the actor (i.e., the knower), that which is acted
strategies could be thought of as avenues to upon (i.e., the known), and the circumstances
ªmodify the environmentÐto remove the under which the action occurred (i.e., the
sources of the miasmaº (Bloom, 1977, p. 71). situation in which the knower confronts the
known). It is within that entirety that the
6.13.5 EXTERNALIZING THE STUDY OF meaning of an action or event must be under-
BEHAVIOR stood. As explained by Allport (1955):
Albeit outdated and dismissed, miasma Perceptual order and stability can be regarded not
theory is offered to focus readers' attention merely as a matter of the appraisal of cues, but also
on nonspecific characteristics of settings and as a more dynamic relationship between the
situations in which disease and dysfunction organism and the environment. When percepts
Environmental Models of Behavior 289
are attained their attainment is likely to involve within them and the shared rules for relating to
direct participation in some process of overt them, influence behavior.
adjustment. Perception and action can be seen to Support for the importance of attending to
have a close functional relationship (emphasis the ecological environment was provided in the
added). (pp. 271±272)
findings of a series of early studies (summarized
in Barker, 1968) on children's behavior across
From a transactional perspective, violent acts school settings. Barker and his colleagues
occurring in a school, for example, would be determined that knowledge of situational
understood in terms of when, how, and where characteristics of such settings resulted in better
they occur, who is present at the time, and how prediction of children's behavior than knowl-
each person present interprets the events and the edge of the characteristics of individual chil-
options available to respond to those events. The dren. Across a number of settings, children
coalescence of those elements gives meaning to acted more like each other within a given setting
the violence and determines how its occurrence than like themselves across settings. To the
influences subsequent events. Among those researchers, measurable properties of settings
events are the responses of others to the violence, appeared to constrain the range of alternative
the likelihood of its continuation by its perpe- responses and opportunities for behavior within
trator(s), and of its adoption by others (Lorion, each setting.
Brodsky, & Cooley-Quille, 1998). Barker and his colleagues used the concept of
As used in this chapter,ªenvironmentalº ªbehavior settingsº to describe such person-
research refers to studies which examine the setting linkages. As explained by Barker:
contributions of setting characteristics to beha-
vior. As explained by Schoggen (1989), environ-
mental studies are exemplified by analyses of the A behavior setting has both structural and dy-
namic attributes. On the structural side, a behavior
physical or built environment on behavior (e.g.,
setting consists of one or more standing patterns of
the design of playgrounds on student interac- behavior-and-milieu, with the milieu circumjacent
tions or of classrooms on reading) and of and synomorphic to the behavior. On the dynamic
physical qualities of a setting on functioning side, the behavior-milieu parts of a behavior
(e.g., noise and lighting levels on classroom on- setting, the synomorphs, have a specified degree
task behavior). Such studies may, however, of interdependence among themselves that is
focus on the ªthe ecological environment greater than their interdependence with parts of
(which) includes also the objectively observable other behavior settings. (1968, p. 18)
standing patterns of behavior of peopleÐthat is,
specific sequences of people's behavior that In effect, a behavior setting refers to a pattern of
regularly occur within particular settingsº behavior which appears regularly under specific
(Schoggen, 1989, p.2). This subset of environ- setting-defined circumstances. As explained by
mental studies must, themselves, be distin- Schoggen (1989): ªFrom this viewpoint, the
guished from work on the ªpsychological environment is seen to consist of highly struc-
environment,º that is,ªthe subjective represen- tured, improbable arrangements of objects and
tation of the objective environment by a given events that coerce behavior in accordance with
person at a particular timeº (Schoggen, 1989, their own dynamic patterningº (p. 4).
p. 3). Such patterns of behavior appear regularly
and predictably; their occurrence is independent
6.13.6 ENVIRONMENTAL MODELS OF of the specific individuals present. These
BEHAVIOR patterns of behavior are linked both in place
(i.e., are circumjacent) and form (i.e., are
As noted, Lewin's (1935, 1944) assertion that synomorphic) to characteristics of the setting
behavior is a function of person and environ- but not to the presence of specific individuals as
ment stimulated inquiry into the contribution of much as to the presence of categories (e.g.,
setting characteristics in shaping behavior. students and teachers; players and coaches) of
Barker, a colleague of Lewin, developed this individuals. Within a behavior setting, the
line of research. In Barker's (1968; updated in behavior and setting are ªinterdependentº to
Schoggen, 1989) view, the distinction between the extent that the former is unlikely to occur
Lewin's concept of ªlife-spaceº or the psycho- outside of the latter and that qualitative aspects
logical environment (i.e., the world as an of the behavior are shaped by characteristics of
individual perceives and is affected by it) and the setting.
the ecological environment (i.e., the objective Examples of behavior settings include the fit
characteristics of real-life settings) makes evi- between the organization and structure of a
dent the need to understand how the physical classroom and the behaviors expected of, and
properties of settings, including the objects displayed by, students and teachers; the distinct
activities of students within a gym, in a library, Sameroff (Sameroff & Chandler, 1975; Samer-
or on a playground's basketball court or off & Fiese, 1989) proposed a transactional-
hopscotch grid. The physical setting and its ecological model for understanding variation in
associated rules make some behaviors highly the outcomes associated with presumably
likely and other behaviors highly unlikely. established risk factors for developmental
Schoggen (1989) explains that neither the disabilities. Unique to this model is a hypothe-
physical nor social aspects of settings preclude sized ªtransactionº between individual and
all but a single behavior; rather, these settings contextual factors. For Sameroff, emotional
aspects make ªactions of some kinds easier than and behavioral development is the product of an
othersº (p. 43). Wicker (1979) explains this ongoing synergistic series of: (i) responses by an
process as follows: individual to situational circumstances and
demands; (ii) alterations of those situational
Behavior settings are self-regulating, active systems. circumstances and demands as a function of the
They impose their program of activities on the individual's responses; and (iii) responses by an
persons and objects within them. Essential persons individual to that altered situation. Individual
and materials are drawn into settings, and dis- and setting characteristics, however, differ in
ruptive components are modified or ejected. It's as their malleability and range of variation.
if behavior settings were living systems intent on
Consequently, it should not be assumed that
remaining alive and healthy, even at the expense of
their individual components. . . . each transaction represents equivalent changes
. . . to summarize some of the essential features of in individual and setting characteristics.
behavior settings. Most of them can be presented Nevertheless, within Sameroff's model, in-
in a single sentence: A behavior setting is a bounded, dividuals and settings evolve continually (albeit
self-regulated and ordered system composed of generally gradually rather than dramatically)
replaceable human and nonhuman components that over time. This element of the theory augments
interact in a synchronized fashion to carry out an substantially the complexity of understanding
ordered sequence of events called the setting pro- and controlling behavioral development. It also
gram. (p. 12) suggests that behavior can be shaped through
controlled changes in the individual, the context,
Although the heuristic potential of Barker's or both. Sameroff's model mirrors the continu-
work on setting characteristics has yet to be ing occurrence and adaptation to events which
aggressively mined (readers are encouraged to characterize the ongoing flow of daily life. It also
review Levine & Perkins, 1987; Moos & Insel, offers a basis for contextualizing variations in
1974; and Wandersman & Hess, 1985 for illus- behavior across situations. In effect, unyielding
trations of the potential richness of this vein), settings would constrain behaviors within cir-
Barker and other environmental psychologists cumscribed parameters. In the most recent
offer a heuristic avenue for understanding and version of the model, Sameroff and Fiese
responding to external contributors to health (1989) make explicit that societal (and, pre-
and pathology. That the concept of behavior sumably, subgroup) expectations have regula-
settings may help unravel interpersonal pro- tory influence on definitions of behavioral roles
cesses within educational settings is strongly and thereby set contextual limitations on
suggested in findings reported by Barker and his developmental outcomes. Insofar as such ex-
colleagues (e.g., Barker, 1968; Barker & Gump, pectations and setting demands are fixed, the
1964; Barker & Schoggen, 1973; Barker & behavioral responses of those within a setting
Wright, 1951; Schoggen, 1989). Extrapolating may be more restricted than assumed or desired.
from that work, it seems reasonable to assume Kellam's (Kellam, Branch, Agrawal, & En-
that aspects of the environments in which people sminger, 1975) Life Course-Social Field model
live, learn, play, and work can be shaped such offers further enhancement of Lewin's and
that they can contribute to optimal adjustment Bronfenbrenner's theories. Kellam's approach
to developmental demands and reduced poten- integrates elements of the biopsychosocial
tial for emotional and behavioral dysfunction. perspective with Erikson's (1963) recognition
that development involves confronting and
6.13.7 TRANSACTIONAL MODELS OF resolving a series of social tasks across the life
BEHAVIOR span. Thus, Life Course-Social Field theory
defines development in terms of movement over
In his biopsychosocial theory of behavior, the life span across diverse settings (i.e., social
Bronfenbrenner (1977, 1979) focused attention fields), each presenting its own demands and
on the synergistic relationship between the adaptive challenges.
individual (e.g., IQ, temperament) and setting The success with which the unique and
(e.g., parental responsiveness) in the processes common tasks associated within and across
of human development. Extending that theory, social fields are resolved is assessed both by
Transactional Models of Behavior 291
oneself and by significant others in those transactional influence is that outcome is

settings. Kellam labels the substance of assess- difficult to predictº (p. 33). Rather than a
ments of one's own psychological state as limitation for intervention design and applica-
ªpsychological well-being.º Examples include tion, this consequence argues for use of indirect/
one's sense of self-efficacy, anxiety, self-esteem, consultation approaches, particularly in the
depression, disappointment, inadequacy, etc. By pursuit of preventive goals. As explained by
contrast,ªsocial-adaptational statusº refers to Sroufe (1997) and Rutter et al. (1997), con-
the assessments which others make of the ceptualizing psychopathology as a develop-
adequacy of an individual's response to these mental phenomenon shifts the focus from the
developmental tasks across the multiple contexts individual to the individual±environment dy-
(labeled ªSocial Fieldsº in Kellam's model) in namic. Particularly important is recognition of
which we live, play, or work, for example. such phenomena as reflecting adaptations to
Unique to Kellam's model is his emphasis on environmental demands rather than as the
the fact that the individuals (i.e.,ªnatural inevitable result of individual failings, unre-
ratersº) who make such assessments vary across solved early experience, biological determinism,
tasks and social fields. In that sense, social fields or other endogenous factors. Within this
are social, that is, they involve exchanges among framework, adaptive states represent points
the players in settings who have setting-related along developmental pathways. Rather than
roles and expectations. Depending on their reflecting linear and deterministic processes
responses, these raters influence for better or whose outcomes are fixed from the outset (e.g.,
worse the individual's resolution of task based on inherited characteristics) or soon
demands. The salience of particular social fields thereafter (e.g., based on early traumatic
and of their respective natural raters changes experiences), such pathways evolve over time
over time and across developmental demands. branching this way and that depending on
Thus, the school for example, has particular specific mixes of adaptive resources, coping
salience during childhood and adolescence but demands, and as yet unknown determinants of
much less so during the adult years. Similarly, as salience at the moment (e.g., Bell, 1986).
peers grow in importance, the family becomes Outcome becomes difficult to predict if one
less salient during adolescence and early adult- requires that knowledge of beginnings implies
hood and more so thereafter. knowledge of endings or vice versa. By contrast,
emotional and behavioral states become man-
6.13.7.1 Linking Inside and Outside ageable if understood in terms of antecedent
processes and likely subsequent presentations
As noted, Levine and Perkins (1997) suggested (some of which may be mutually exclusive but
that an important obstacle to the widespread most of which may overlap or co-occur). Such a
adoption of alternative perspectives of emo- view of pathogenesis has multiple implications
tional and behavioral problems (i.e., as adapta- (Sroufe, 1997):
tions to setting conditions rather than as (i) adaptation and maladaptation represent
reflections of endogenous psychopathology) evolving rather than established conditions
and their resolution (e.g., indirect/consultation determined by what has occurred in the past,
and preventive approaches rather than psy- what is currently happening and the range of
chotherapy) was the absence of ªalternate options allowed by cultural, setting and indivi-
theoretical conceptualizationsº (p. 60). Such dual circumstances. This temporal quality of
an alternative is now available in the growing functional states links what has been with what
body of work linking internal processes and is and the likelihood, but not certainty of
external conditions. Environmental analyses subsequent states. Kandell's ( ) ªgateway theo-
reviewed thus far (e.g., Barker, 1968) provide ryº of drug involvement exemplifies this prin-
evidence supporting the impact of external ciple. Use of alcohol or tobacco, for instance, is
factors on emotional and behavioral function- associated with an increased probability of
ing. Developmental theorists such as Sameroff marijuana use just as the latter is associated
(e.g., Sameroff & Fiese, 1989), Kellam (e.g., with an increased probability of use of cocaine
Kellam et al., 1975), Bronfenbrenner (1979), and or heroin. Any individual may, however, not go
Rutter (e.g., Rutter et al., 1997) extend our beyond a particular gate; hence the disconti-
understanding of the programmatic significance nuity between antecedents and outcomes (Kan-
of this impact by clarifying the transactional del, Single, & Kessler, 1976);
processes by which external and internal events (ii) because many characteristics of experi-
influence each other. ence and environment are shared across indi-
Acceptance of such insights is heuristically viduals (e.g., who live in a given neighborhood
important for multiple reasons. Orford (1992) or are raised within a common culture), diverse
notes that ªone of the consequences of complex, pathways may lead to a common outcome.
General systems theorists and developmental be followed. Understanding that path will likely
psychologists refer to this pattern as ªequifin- require understanding the history of the resis-
alityº (Cicchetti & Rogosh, 1996; Orford, 1992). tance encountered. Some of it may reflect the
Highly diverse economic, familial, educational prior experiences of a specific individual; some
and occupational antecedents, for example, may instead represent a community's, a neigh-
have been associated with drug involvement; borhood's, or a family's post-hoc response to the
(iii) similarly, although individuals may behavior or needs of others. Some paths will
share common antecedents (e.g., poverty, being proceed in a relatively linear fashion; antece-
reared in a single parent household; a history of dents are followed by clinically defined emo-
physical or sexual abuse) differences in circum- tional or behavioral problems. Removing,
stances subsequent to those antecedents give neutralizing, or interrupting antecedents pre-
rise to a variety of outcomes (e.g., depression, vents the undesired outcome.
alcoholism, conduct disorder). General systems Unfortunately, few mental health conditions
theorists and developmental psychologists refer can be linearly modeled. More typical is Sroufe's
to this pattern as ªmultifinalityº (Cicchetti & (1997) portrayal of emotional and behavioral
Rogosh, 1996; Orford, 1992); development as the branches of a tree or the
(iv) by combining a, b and c, one appreciates meanderings of its roots. Within this perspective,
that developmental pathways offer multiple growth and survival requires maximizing one's
opportunities for changing direction and hence access to necessary resources regardless of the
influencing outcome. Branching off may reflect impediments encountered in the environment.
the occurrence of positive or negative events At any point in time, emotional and behavioral
(e.g., an increase in family income, parental status reflects the cumulative effects of its
death or divorce), the addition of individual or antecedents. The further back one traces a
circumstantial resources which enhance or re- branch the more completely one can understand
duce adaptive capacity (e.g., acquisition of what has been and will be encountered. With
interpersonal problem-solving skills or access such information, the better one can predict the
to a caring teacher) or a change in the environ- probability of the branch's likely direction.
ment (e.g., moving to a more or less violent Where the branch connects to the trunk is but
neighborhood). Whatever the case, a seemingly one element to be considered in predicting its
normative or pathogenic process may be inter- various termini. That beginning is likely to be
rupted and its direction changed for good or ill; common across many outcomes (i.e., the
(v) recognition that developmental trajec- principle of multifinality). Equally likely is that
tories can be altered must be tempered with termini in close proximity may have begun at
appreciation of the limitations of that assertion. different points along the trunk (i.e., the
It appears that the further along a path one has principle of equifinality). Adding to the com-
gone and the longer the pathogenic process has plexity is that some branches will end close to
been underway, the less likely it is that the path's where they began, whereas others continue on
direction can be altered. This seems to be the case toward other terminating points. Presumed
because the capacity to recognize, access and use antecedents (e.g., alcohol or tobacco use) for
additional resources in the environment to adapt some conditions (e.g., substance dependence or
to health compromising situations depend on addiction) may, for many, represent an endpoint
prior experiences, verbal abilities, interpersonal (i.e., substance use is limited, controlled, or even
skills etc. In effect, the further along a path one ended). In other cases, however, the process
has traveled, the more likely one is to reach its continues toward dependence and addiction.
end point. ªMore likely,º however, refers to Common antecedents leading to diverse
probability rather than inevitability! outcomes; diverse antecedents leading to com-
The conceptual option presented links exo- mon outcomes; the co-occurrence of multiple
genous and endogenous processes in a way that outcomesÐmay be perceived as too complex
enriches comprehension of etiological processes and misunderstood an etiological model to
and expands the avenues for interventions to inform intervention design, especially preven-
influence those processes. Developmentally, tive interventions (Lamb & Zusman, 1981).
emotional and behavioral patterns reflect adap- Presumably, one should wait until the die is cast,
tations to situational demands based on indi- the nature of the pathology is clear, and
vidual and environmental resources and the treatment can be selected and applied. Public
adaptive history of both the individual and the health practitioners might accept this approach
setting. (Mal)adaptation may proceed linearly were the costs of delay (health related and
or circuitously, winding like a river or branching financial) minimal, the effectiveness of treat-
out like the roots of a tree. Depending on the ment certain, and the secondary consequences
resistance encountered as well as what has come of the disorder acceptable. The common cold
before, one among many alternative paths will and the 24 hour flu fit within these parameters.
Shifting to a Prevention Focus 293
Most emotional and behavioral disorders, Within this framework, primary prevention
however, do not. interventions are implemented prior to caseness.
Alternatively, the aforementioned complexity Successful interventions reduce prevalence (i.e.,
may be recognized as allowing for, indeed overall presence of cases of a target disorder in
requiring, nonspecific interventions focusing the population) by reducing incidence (i.e., the
on common etiological factors, be they indivi- occurrence of new cases). Potential recipients of
dual, environmental, or transactional. Targeting such interventions range from the population at
common risks factors or pathways which are large, to asymptomatic subgroups targeted on
epidemiologically linked with undesirable out- the basis of epidemiologically-defined risk, to
comes has the potential for impacting simulta- subgroups presenting prodromal signs antece-
neously multiple outcomes. Simply stated, dent to diagnostic status. By contrast, secondary
interventions targeting common antecedents interventions seek to lower prevalence by
may impact on multiple pathways and thereby reducing the duration of caseness, that is,
serve as a stone which kills (or at least weakens) through the application of effective treatment.
multiple birds! By aggregating the measured Combinations of sensitive screening procedures
preventive effects across those outcomes sharing which identify cases early and involve them in
common risks, the true impact of such inter- treatment exemplify this category. Secondary
ventions may finally be documented (Lorion et approaches seek both a return to premorbid
al., 1989). Applying the principle of multifinality status and avoidance of subsequent episodes.
to intervention design leads to targeting a limited Finally, tertiary interventions reduce the long-
number of shared risk factors and assessing their term disabilities and sequella consequent to
impact across alternative pathogenic expres- caseness. Rehabilitation strategies and support
sions. Similarly, the principle of equifinality services exemplify tertiary approaches. Insofar
requires that interventions intended to reduce as they enable a person with schizophrenia to
the occurrence of a specific outcome must target live independently, tertiary goals are achieved.
the various pathways and risks associated with If recurrence of disabling symptoms is avoided,
that outcome. In both instances, basic elements secondary goals are achieved.
of developmental theory supported by epide- Ideally, primary prevention interventions are
miological findings argue against the likelihood preferable. This assumes, of course, the avail-
of documenting substantial evidence of preven- ability of necessary etiological information,
tive outcomes if only a limited number of risks access to the population at risk, and effective
factors are targeted with the intent of impacting intervention strategies. It also assumes that the
a single form of disorder or dysfunction. As intervention's effects are, at worse, neutral. This
noted below, neither prevention theory nor the is a particularly important point given that the
traditional intervention taxonomy made that diseases and disorders of most interest to mental
point clearly. health are relatively low-frequency events.
Hence, unless substantial risk information is
6.13.8 SHIFTING TO A PREVENTION available and targeting is very precise, it is most
FOCUS likely that the majority of those receiving the
intervention are unlikely to manifest the disease
Initial forays by the mental health sciences or disorder in the absence of the intervention. If
and professions into preventive efforts were led the intervention has iatrogenic consequences,
by Caplan (1964) who recognized that the then these individuals may be at greater risk for
mental health disciplines had to move beyond those consequences than to the etiological
sole reliance on treatment if they were to serve outcome to be avoided. Dismissal of this concern
public needs. To organize initial efforts in this notwithstanding (Albee, 1986), evidence for
direction, Caplan urged mental health to adopt caution has been reported (e.g., Lorion, 1987;
the goals of and the classification system for Sameroff & Fiese, 1989) although the frequency
prevention extant in public health at the time of negative consequences appears to be low
(Commission on Chronic Illness, 1957). This (Durlak & Wells, 1997). Secondary and tertiary
system was centered around the epidemiological prevention efforts, by contrast, are targeted only
concept of ªcaseness,º that is, confirmation that to those meeting diagnostic criteria and hence
the diagnostic criteria defining a syndrome were having confirmed need for the intervention.
met. Intervention categories were differentiated As noted earlier (Lorion, 1983), the classic
within this system in terms of their proximity to public health triad of approaches applied to the
the targeted condition's fulfillment of diagnos- disorders (e.g., infectious diseases) and etiolo-
tic criteria, that is, meeting the symptomatic gical processes of primary concern to public
definition of a syndrome. Preventive interven- health practitioners. The applicability of its
tions were designed to reduce the prevalence of a underlying causal assumptions, however, to
targeted disease or disorder. emotional and behavioral disorders has been
challenged from the outset (e.g., Albee, 1982; and hence a more focused (and potentially more
Lamb & Zusman, 1979). As reflected in the iatrogenic) intervention can be justified. Ex-
work of Brofenbrenner (1979), Rutter (1989), amples include programs targeted to families
and Sameroff and Fiese (1989), there is an considering marital separation or divorce
emerging appreciation of the etiological com- (Wolchik et al., 1993) or the recently widowed
plexity of emotional and behavioral problems (Silverman, 1988).
involving biological, psychological, social, and Indicated interventions target individuals
environmental parameters. This complexity (rather than subgroups) who present risk factors
obscures determination of the onset of patho- or prodromal signs indicating substantial
genic processes, the presence of disorder, and individual risk for subsequent disorder. Exam-
thereby designation of ªcasenessº (Lorion et al., ples of these approaches include programs for
1989). Unresolved, these challenges produce women presenting early indices of depression
disagreements in the categorization of primary (e.g., Vega, Valle, Kolody, & Hough, 1987) and
and secondary interventions and obstacles to adolescents referred to juvenile court for status
empirical verification of their efficacy. In either offenses (Lochman, 1992). It also includes Olds'
case, they allow little room for consideration of substantially validated approach to assisting
the principles of equifinality and multifinality in high-risk adolescent mothers (Olds & Korfma-
intervention design or evaluation. cher, 1997, 1998a, 1998b).
Gordon (1983, 1987) has proposed an alter- Gordon's proposal was intended to stimulate
native taxonomy for organizing preventive development of preventive efforts and to make
efforts which allows for consideration of these explicit how they were clearly distinct from
most important developmental principles. Gi- treatment of symptoms and syndromes. In an
ven the low base rate at which emotional and important sense, Gordon (1983) proposal offers
behavioral disorders occur in the general a conceptual expansion of the original ªPrimary
population, Gordon's system also allows for preventionº category. His approach highlights
consideration of both the financial costs and the the breadth of opportunity available to influence
iatrogenic potential of the interventions. prevalence by intervening along that functional
Weighting expected intervention risks with continuum ranging from health through various
target selection, Gordon (1983) proposed that prodromal stages prior to meeting diagnostic
ªuniversal,º ªselective,º and ªindicatedº inter- criteria. The richness of this alternative system
ventions should be designed for and targeted to lies in its clarification of concepts of ªriskº and
ªpersons not motivated by current sufferingº ªvulnerabilityº as applied to individuals, situa-
(p. 108) and neither currently seeking nor in need tions, and their combinations. It also lies in its
of treatment. Universal interventions are applied clear distinction between the end-state condi-
to the population at large and combine low costs tions to be avoided (e.g., substance abuse or
per contact with limited likelihood of iatrogenic depression) and susceptible individuals. Samer-
consequences. Examples of such approaches off (1977) made a similar plea in his early
include public service announcements advocat- warning to prevention scientists that their efforts
ing seat-belt use and physical exercise or must not compromise respect for the humanity
discouraging tobacco use and the consumption of the recipients of those efforts. In his advocacy
of alcohol during pregnancy. In the mental for health promotion efforts, Cowen (1996)
health realm, universal interventions include the similarly urged program developers to recognize
ªFriends can be good medicineº program that removal or reduction of risks and vulner-
implemented in California to enhance use of abilities could leave individuals both empowered
social support resources and emerging strategies and likely to reach their potential. In their meta-
to teach parenting skills to adolescents. Perhaps analytic study of primary prevention programs,
the designator ªuniversalº may also be applied to Durlak and Wells (1997) report clear evidence of
the generic nature of the risk factors targeted by the value of skill-building and competency
such interventions. If so, the difficulty of enhancement as a means of avoiding dysfunction
measuring their impacts becomes understand- as well as improving quality of life for at-risk
able given the multiplicity of outcomes which youth.
may be affected at undefined points in the future.
Selective interventions are targeted to seg- 6.13.9 MERGING INDIRECT/
ments of the population for which there is an CONSULTATION STRATEGIES
epidemiologically established risk. Selection WITH PREVENTION GOALS
may be based on identified links between
gender, ethnicity, economic status, or family Whatever classificatory scheme is adopted,
history, for example, and the presence of epidemiology and developmental psycho-
emotional or behavioral disorders. Targeted pathology provide important conceptual and
subgroups have a higher likelihood of disorder methodological foundations for meaningful
Merging Indirect/Consultation Strategies with Prevention Goals 295
advances in prevention (Mrazek & Haggerty, sumptive bases of definitions of problems and
1994). Application of case±control methodol- solutions, and thereby opened new perspectives
ogy, for example, enables epidemiologists to and alternatives to those whom they served. The
discern potential risk and protective factors recipients of their services, in turn, impacted on
associated with symptomatic and syndromal the lives of the children and families deemed to
expression. Developmental psychopathology's be at risk.
longitudinal methods offer insights into the Reviews of mental health consultation (e.g.,
pathogenic processes defining vulnerability and Bloom, 1984; Gallessich, 1986; Mannino &
allow for modeling the sequence of states and Shore, 1986) reveal both the promise and
events which define the trajectory from health to limitations of attempts to extend these early
dysfunction, to distress, and potentially (but not efforts to meeting the mandates of the Com-
necessarily) to pathology. As noted, examina- munity Mental Health Centers Act. Whether
tion of developmental processes from a system's focused on the needs of a client being provided
perspective brings to the forefront the impor- mental health services, of the provider deliver-
tance of the principles of equifinality and ing those services or of the agency in which those
multifinality. In turn, the application of these services, were delivered, consultation was gen-
principles argue for the design and implementa- erally targeted to responding to the needs of
tion of preventive interventions which target those with identified dysfunction or incipient
multiple risk factors linked to one or more forms of disorder. The delivery system itself was
negative emotional and behavioral outcomes. not altered nor were the conditions for provid-
This view is supported by Mrazek and Hall ing its services.
(1997) who question Durlak and Well's (1997) What seems necessary at this time is the
decision to exclude programs which sought to application of indirect/consultation strategies
improve academic achievement and reduce which redefine service delivery systems and
substance use from their meta-analysis of thereby impact on the common risk factors
preventive interventions: seemingly essential to the etiology of diverse
emotional and behavioral problems. Durlak
Even though this is a legitimate way to narrow the and Wells' (1997) meta-analysis of prevention
huge task they faced, it also represents one of the programs for children and adolescents makes
main problems in prevention science today, that is, evident the promise of such interventions.
the categorical approach to mental, social, educa- Similar optimism is supported by the findings
tional, behavioral and legal problems. Many of of the recent Institute of Medicine review of the
these problems have common risk factors that state of preventive science (Mrazek & Haggerty,
interact in complex causal chains. Addressing
1994). What both reviews underline is the
clusters of risk and protective factors increases
the chances of preventing multiple problems in importance of focusing on building skills in
many areas of functioning. It is the accumulation the individual at risk or in those who surround
of multiple proximal outcomes across various the individual. Preventive interventions with the
domains of functioning, such as educational most promise appear to strengthen basic
status, social adjustment, and behavioral and academic skills, interpersonal resources, and
emotional well-being that will be the most con- the responsiveness of the social systems which
vincing arguments for the effectiveness of preven- can influence developmental outcomes (Durlak
tion. (Mrazek & Hall, 1997, p. 223) & Wells, 1997; Lorion, 1990; Mrazek &
Haggerty, 1994). The best of such work is
Impacting on such a diversity of targets theory-based, systematic and, most impor-
requires in my view the application of indirect tantly, incremental (Price, 1997; Price & Lorion,
and consultation strategies to maximize 1989). Like the pieces of a puzzle whose image
achievement of desired outcomes. As noted gradually emerges, program development pro-
earlier in this chapter, such approaches char- ceeds through the sequence depicted by Price
acterized early twentieth century attempts to (1983) as the ªfour domains of prevention
respond to the needs of children and families at scienceº (p. 291). These domains include: (i)
risk for emotional and behavioral problems. problem analysis (i.e., epidemiological and
Across multiple settings and a diversity of goals etiological studies); (ii) innovation design (i.e.,
relating to improving the status of those in need, program development); (iii) field trial (i.e.,
such early efforts at consultation applied ex- efficacy research); and (iv) innovation diffusion
pertise in developmental processes and mental (i.e., effectiveness research).
health to enhancing the effectiveness with which A most important element of Price's model
parents, teachers, and other members of a for the development of preventive intervention
community met their responsibilities. Consul- was the interconnectedness of these domains. In
tants observed behavior, examined policies, and effect, Price recognized how progress through
procedures, identified and examined the as- these stages modifies one's initial understanding
of the originating problem and hence catalyzes included the reduction of pre- and perinatal
the refinement of each subsequent stage. Earlier, risks to decrease epidemiologically established
Cowen (1980) had differentiated the initial two risks for health problems in late pregnancy,
domains as ªgenerativeº and the latter two as delivery complications, and associated develop-
ªexecutiveº components of prevention science. mental sequella for the infant. The program also
Generative studies have scientific importance sought to alter parenting practices associated
beyond their capacity to inform the design and with negative child health and developmental
implementation of interventions for they inform outcomes. Finally, the program sought to
us ªabout the very processes whereby functional improve maternal life course by extending the
and dysfunctional states develop and are interval between the initial and subsequent
maintained. Preventive research can increase pregnancies and thereby increase the likelihood
our understanding of the environmental para- of mothers returning to school, obtaining work,
meters which engender, maintain, and modify and becoming independent of welfare. Women
human behaviorº (Lorion, 1983, p. 264). The were randomly assigned to intervention or
continuing heuristic value of Cowen's distinc- control conditions and the intervention was
tion between generative and executive studies provided initially by registered nurses (a com-
and Price's four domains is reflected in the parison of the differential effectiveness of nurses
Institute of Medicine's analysis of the state of and paraprofessionals is currently underway).
prevention science. To catalyze the field, the The program began in Elmira, NY with a
report advocates that the field adopt the predominantly White, rural sample and was
ªpreventive intervention research cycleº as its replicated and extended with an urban, African-
map for the systematic accumulation of in- American sample in Memphis, TN and a diverse
formation (Mrazek & Haggerty, 1994). Opti- sample in Denver, CO. The initial cohorts have
mistically, they conclude: now been followed for nearly two decades. In
considering the findings, the complexity of this
If the research standards and methodology out- program becomes evident. Through contacts
lined here are systematically and rigorously ap- with the home visitor during the final stages of
plied within the preventive intervention research the pregnancy, mother's knowledge, attitudes,
cycle and the guidelines on cultural, ethical, and and behaviors concerning health compromising
economic issues are carefully considered at each risks (e.g., diet, exercise, alcohol, and tobacco
step, prevention research will yield progressively use) are to be influenced with the hope of
more powerful results over the next decade. The
reducing birth complications and optimizing
ensuing development of prevention into a science
will provide a firm base of knowledge for policy- fetal development. Following the birth, home
makers. This knowledge will inform their decisions visitation continues its focus on maternal health
on the allocation of available resources toward the as well as child care, developmental processes,
ultimate goal of realizing the opportunities pre- and, importantly, the implications of maternal
sented by the science for the alleviation of the choices on the life course. The latter is important
personal and societal suffering and burdens asso- insofar as the mother assumes control of the
ciated with mental disorders. (pp. 408±409) timing of subsequent pregnancies as she
recognizes its implications for her educational
The validity of this assertion is clearly repre- and employment options and their implications
sented by the Home Visitation Program devel- for her immediate and long-term economic
oped by Olds and colleagues and described in situation.
detail in two special issues of the Journal of From this perspective, the program delivers a
Community Psychology (Olds & Korfmacher, direct service to the mother. The lack of a mental
1997, 1998a, 1998b). Built slowly and metho- health diagnosis notwithstanding, the service
dically over more than two decades, this pro- appears similar to many forms of treatment. The
gram exemplifies the challenges and potential visitor meets regularly with mother to discuss
payoffs of the systematic pursuit of preventive issues, provide information, and offer counsel
goals. Of direct relevance to this chapter is that and support. The notable difference, however, is
the program relies on a mixture of direct and that at least a portion of the changes in the
indirect intervention components to accomplish mother are intended to alter permanently her
its goals. These components derive from recog- behavior toward her child. Not unlike the Child
nizing the complementary aspects of self-effi- Guidance and Settlement House social pro-
cacy, human attachment, and human ecology grams of the early twentieth century, the Home
theory. Recipients of the program's direct Visitation program represents a form of
intervention are primiparous (<26 weeks ge- indirect/consultation service. Toward this goal,
station), young (<19 years of age) women who the program strategy is designed to enhance the
are deemed at risk because they are single and/ mother's capacity to parent and to assert herself
or low-income. Program goals for these women in employment and social service situations. If
References 297
this element of the program is successful, tion, April, 1998) supports my impression that
significant risks for the child (e.g., develop- what differentiates his approach from its
mental lags, physical or sexual abuse, early counterparts is not only reliance on licensed
academic failure) can be reduced which have nurses as the providers (the Denver replication
been linked epidemiologically to school failure, specifically examines the differential impact of
conduct disorder, substance involvement and, nurse and paraprofessional provider) but its
later in life, early pregnancy, and cross-genera- clear intent to produce lasting changes in the
tional child abuse. mother. In effect, an essential component of the
Changes in a mother participating in the Home Visitation program is for the visitor to
Home Visitation program, therefore, can ripple make herself unnecessary, that is, to achieve the
across the family, home, neighborhood, and consultant's goal of putting oneself out of
other levels. Assuming that the program's business. Echoing the commitment of the Child
effects on the mother are lasting, developmental Guidance Movement (Mannino & Shore, 1986),
benefits observed in the developmental course the program enabled the mothers both to solve
for the firstborn should hold for subsequent immediate problems and to anticipate and
children as well. To the extent that mother's thereby avoid or solve future problems. My
overall heath behaviors and especially prenatal impression is that Olds' approach empowers the
health behaviors are improved, further reduc- mothers and embodies the principle reflected in
tions in neonatal risk should occur for sub- the adage ªgive me a fish and I eat for a day.
sequent children. If the intervention represents a Teach me to fish and I eat for a lifetime.º
viable approach to assist women to move from
welfare to employment, program effects sup-
port the achievement of indirect/consultative 6.13.10 FINAL COMMENT
goals at the public policy level. The position presented in this chapter is that
Results reported thus far confirm the benefits significant health and mental health goals can be
of merging direct and indirect strategies in the achieved through the development, evaluation,
pursuit of preventive goals. Summarizing find- and dissemination of theory-based, scientifically
ings from the Elmira and Memphis samples, validated, and politically and economically
Olds et al. (1998) report that compared to supported preventive interventions delivered
mothers randomly assigned to the control through the application of indirect/consultation
condition, those assigned to the Home Visita- strategies. A review of the history of human
tion intervention smoked less and improved service strategies over the past century and
their diets during pregnancy, had fewer hyper- particularly since passage of the Community
tensive disorders and preterm deliveries. Post- Mental Health Centers Act documents repeated
natal differences favoring the intervention attempt to pursue this goal. Good intentions and
group included fewer health care encounters sincere commitment, however, have not been
for the infants relating to injuries and ingestions sufficient to place this effort into the fabric of the
and, in the Elmira sample, lower rates of child human and social service network. For that to
abuse and neglect. These results suggests that occur, I am arguing, requires a combination of
intended improvements in maternal caregiving theoretical justification, flexibility in profes-
were achieved. During the four-year period sional attitudes and roles, and viable examples of
following program participation, Home Visited effective applications. All of those conditions
mothers had fewer pregnancies; more program appear to be presently available! Ideally, this
mothers completed their education, became chapter will contribute in some small way to the
employed, and independent of welfare than discipline's recognition and seizure of this
control mothers. Cost-effectiveness analyses opportunity.
confirm the long-term economic benefits of this
program; program costs are recovered within a
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6.14
Working with Images in Clinical
Psychology
ANN HACKMANN

6.14.2 AN OVERVIEW OF THE USE OF IMAGERY IN THERAPY 302
6.14.3 TYPES OF IMAGES IN PSYCHOLOGICAL DISORDERS 304
6.14.4 WORKING WITH IMAGES IN BEHAVIOR THERAPY 307
6.14.4.1 Desensitization 307
6.14.4.2 Covert Conditioning 307
6.14.4.3 Implosion and Imaginal Flooding 308
6.14.4.4 Reliving Treatment in Post-traumatic Stress Disorder 309
6.14.4.5 Eye Movement Desensitization and Reliving 309
6.14.4.6 Thought Stopping 310
6.14.5 WORKING WITH IMAGES IN COGNITIVE THERAPY 310
6.14.5.1 Images and Memories in Cognitive Therapy 310
6.14.5.2 Eliciting Images and their Meanings 311
6.14.5.3 Transforming Images and their Meanings 312
6.14.5.4 Working with Beliefs about Having Images, Intrusive Memories, and Nightmares 313
6.14.5.5 Working with Core Beliefs Using Imagery Techniques 313
6.14.1 INTRODUCTION reconstructions (Bartlett, 1932) that can be

altered or even partly created by varying
Images are defined as contents of conscious- retrieval procedures (Loftus & Palmer, 1974).
ness that possess sensory qualities, as opposed These observations give weight to the idea that
to those which are purely verbal or abstract. some memories are in fact more like imaginative
This definition embraces dreams and waking images, although these may be as vivid and
images of various kinds. Whilst images can have convincing as ªrealº memories. However, this
qualities associated with any of the sensory distinction may be a difficult one to make, since
modalities, it seems that visual imagery is the it is also true (as discussed later in this chapter)
most common (Horowitz, 1970). Memories, that imaginative images themselves contain
too, can come to awareness as mental contents much input from memory, even though the
with sensory qualities, most vividly in the case of person having the image may not be aware of
ªflash bulbº memories, and also in intrusive the connections with their past.
memories and reliving experiences following Among the contents of consciousness are
trauma. Memories themselves are not reexcita- verbal thoughts and images in various modal-
tions of fixed traces, but are imaginative ities, some of which are considered to be
301
302 Working with Images in Clinical Psychology
memories. One might wonder why one would material available in a verbal store. There are
choose to work on imagery rather than purely parallels here with what have been referred to as
verbal thought. Two possible reasons are that primary and secondary process thinking (Freud,
images condense a great deal of information, and 1962).
they reveal layers of meaning which are idio- There are other properties of images which
syncratic. It has also been suggested (e.g., Paivio, affect their usefulness in therapy. They may
1986; Singer, 1974) that imagery via sensory occur spontaneously, but they can also be
modalities is one of several major coding systems deliberately evoked, transformed, or sup-
the brain has for organizing and storing experi- pressed. They can reflect perspectives on the
ence, and that images are likely to afford greater past, the present, or the future, and can be literal
emotional arousal than the verbal encoding or symbolic. They can appear to be veridical
system. Buzan and Buzan (1997) suggest that memories, or at the other end of the scale they
images are often more evocative than words, and can be seen as imaginative images. However,
are more precise and potent in triggering a wide their content is neccessarily determined by
range of associations. Thus, changing or trans- experience.
forming an image might be hypothesized to be
more likely to bring about a significant emo-
tional shift than challenging a verbal thought. 6.14.2 AN OVERVIEW OF THE USE OF
When dramatic, life altering events occur IMAGERY IN THERAPY
people tend to remember a great deal of detail
about the circumstances in which the event In the history of psychology ªmental con-
occurred. Such memories are called ªflashbulb tentsº have at times been seen an appropriate
memories,º and it almost appears as if the mind area of study (e.g., by the early introspectionists,
takes a kind of photograph of the situation at such as William James, Galton, and Titchener),
such times. An example would be the way in and at times relegated to the essentially
which everyone can remember where they were unknowable ªblack boxº (e.g., by Skinner and
when the death of John F. Kennedy occurred Watson). Indeed, Brown (1958) expressed a
(Ornstein, 1992). Work in post-traumatic stress prevailing attitude by writing that ªIn 1913 John
disorder (PTSD; Ehlers, 1997) suggests that Watson mercifully closed the bloodshot inner
during traumatic incidents processing may be eye of American psychology. With great relief
data-driven rather than semantic and memories the profession trained its exteroceptors on the
may be in a fragmented, sensory form, with laboratory animal.º However, early in the
associated high affect when they are recalled. history of behavior therapy imaginal material
Such memories are often deliberately avoided by crept back into the arena, and was used instead of
the client, although they reappear as intrusive in vivo material, for example, in various forms of
memories, nightmares, and spontaneous experi- exposure therapy, such as Wolpe's desensitiza-
ences of reliving. Brewin, Dalgleish, and Joseph tion (Wolpe, 1958) or Stampfl's implosion
(1996) have suggested that there are two types of therapy (Stampfl & Levis, 1967) and imaginal
memory, namely verbally accessible memories flooding (e.g., Foa, Skeketee, & Grayson, 1985).
and situationally accessible memories (SAMS). Images have also been used in other behavioral
The latter are not verbally accessible, but may be treatments, such as various types of covert
triggered by sensory environmental cues or conditioning (Cautela, 1977). Wolpe (1958)
emotions which match those present during legitimized the use of covert processes within a
the trauma. Several other writers have suggested behavioral framework through the assumption
that there may be a number of different that if someone is led to imagine particular events
representation systems that are involved in the this can lead to predictable changes in behavior.
processing of information (cf the Interacting Jacobsen (1942) had also paved the way for this
Cognitive Subsytems approach, Barnard & work, by demonstrating that simply imagining a
Teasdale, 1991; and the SPAARS model, Power situation like running produced responses in the
& Dalgleish, 1997). body such as those produced by real running. It
Following resolution of trauma, memories had also been shown that imagining a feared
seem to be stored in a more orderly, narrative situation produced evidence of the ªfight or
form which is less fragmented (Foa, Molnar, & flightº reflex, with changes, for example, in the
Cashman, 1995) and they are less likely to be galvanic skin response (GSR). In behavior
upsetting to recall, or to be evoked involuntarily therapy, images have been used to provide
by sensory cues. Such observations support the attenuated forms of both stimuli and responses.
idea that there may be several ways of encoding Despite the use of imaginal material the main
material, and there may be a place in therapy for therapeutic techniques used in behavior ther-
bringing more fragmented imaginal material apy were thought to have been derived from
into awareness in order to integrate it with other learning theory, and to involve classical and
An Overview of the Use of Imagery in Therapy 303
operant conditioning, deconditioning, and can offer useful methods of identifying key
extinction. The cognitive therapies took a fresh cognitions (Arnkoff, 1981).
approach by emphasizing the fact that between For this reason it may be useful to consider
stimulus and response there appear to be some of the earlier uses of visualization in
appraisals, which can be worked on directly, psychiatry and clinical psychology. The first
with profound effects on behavior and emo- clinician credited with eliciting images to treat
tion. These appraisals include ªmeanings, patients was Breuer (see Freud & Breuer, 1955).
significances, and imageryº (Beck, 1970), and In 1881, when Freud was his student, he treated
we are advised that in cognitive therapy we Anna O. by hypnotizing her, and encouraging
should attend to thoughts and images (Beck, her to produce what he called fancies, or
Laude, & Bonhert, 1974; Ottaviani & Beck, daydreams. Freud describes the way in which
1987). More specifically, Beck (1976) held that her symptoms of hysterical paralysis would
meanings were the things we needed to change, disappear, when in hypnosis she was made to
and that these are accessible through thoughts remember the situation and associative connec-
and images. The picture is further complicated tions under which they first appeared, provided
by the fact that not all appraisals are necessarily free expression was given to the emotions these
in full awareness or reported spontaneously, evoked. Later Freud applied similar techniques,
although they are potentially accessible to but he abandoned the use of hypnosis when he
consciousness. realized that patients who could not be
Also within a cognitive therapy framework, hypnotized could still produce similar types of
Freeman (1981) and Freeman and Boyll (1992) early traumatic memory images and affect.
discuss the way in which the images in dreams Initially these occurred in response to the
and fantasies provide access to the individual's suggestion that a memory would come to mind
idiosyncratic interpretations of reality, and when Freud put his hand on the patient's head,
distortions therein. This is also true where but this was later altered to an emphasis on free
visual imagery accompanies strong emotion, association and the analysis of dreams and
and such images can form a basis for the symptomatic acts. Freud considered images to
reexamination and restructuring of beliefs. be part of primary process thinking, more
In an interesting paper on the use of Gestalt primitive than ordinary thinking, developed
techniques in cognitive therapy, Edwards (1989) earlier in childhood, and more direct, immedi-
briefly reviews the use of directed visualization ate, and less restrained by logic. He also felt that
techniques in Tibetan Buddhism, Jung's active memory images were often not lost to the
imagination (Watkins, 1976), Assagioli's (1965) person, but stored in the unconscious.
guided fantasy in psychosynthesis, Leuner's In hypnosis, both imaginative and memory
(1984) guided affective imagery, and the images may be elicited, again whilst the patient
imagery psychodrama of Perls and other is in a deeply relaxed state. Age regression
Gestalt therapists (Perls, 1971; Stevens, 1971). techniques are used to evoke memory images,
He also describes its application to the treat- from earlier in the patient's life, or even in some
ment of depression (Shultz, 1984) and phobias cases from supposed past lives. These can be
(Habeck & Sheik, 1984), and in controlling pain extremely vivid and realistic, and this capacity
(Bresler, 1984) and increasing resistance to of people in relaxed states to be able to virtually
cancer (Hall, 1984). Much fuller reviews of relive certain experiences has been noted by
many imagery techniques and their theoretical many therapists. Grof (1976) has described such
backgrounds have been given by Singer (1974) experiences in his patients who explored altered
and Samuels and Samuels (1975). It is beyond states of consciousness under the effects of LSD,
the scope of this chapter to review all previous or during holotropic breathwork sessions,
attempts to treat physical and psychological following hyperventilation and listening to
disorders using imagery techniques, so the main music whilst physically relaxed. Where memory
focus will be on the major work done in this area images are evoked using such methods they may
by clinical psychologists, working in the encompass sensory material in any or all
cognitive-behavioral framework, with the modalities, and associated affects. The same is
stance of the scientist practitioner. However, true with images that can be recognized as
as Edwards points out, work in different imaginative images, leaving a gray area where it
theoretical frameworks is still worth studying, is impossible to say to what extent a veridical
since despite its dissimilar surface character- memory has been evoked, and thus making it
istics the cognitive restructuring that takes place important to consider the idea that some
through guided imagery has close affinity to memories may be ªfalseº ones, a problem which
that which takes place through guided discovery Freud himself encountered.
in cognitive therapy, and techniques such as In the section on working with images in
those used by Gestalt therapists, for example, cognitive therapy some attention will be paid to
the restructuring of memories, a topic which some extent, and suggestions made for ways in
also has relevance in the treatment of PTSD, which the image may be manipulated or
where treatments based on the repeated reliving controlled. An example would be Leuner's
of traumatic memories seem to hold the most Guided Affective Imagery (Leuner, 1969). The
promise (e.g., Foa, Rothbaum, Riggs, & therapist suggests a theme that the patient then
Murdock, 1991). Edwards (1990) has written works with. They may be asked to visualize a
a masterly review of work on early traumatic scene such as a mountain, a meadow, a house, or
memories in various theoretical frameworks, a stream, or they may evoke an image of a
including the Freudian approach. Freud was relative, a sexual partner, or someone of their
initially very interested in early memories, but own sex. Within the imaginary scene they could
later moved away from his work on this topic, be prompted to make a journey, and then deal
partly because he came to believe that some of with the symbolic material which appears. This
the memories reported were in fact fantasies or may involve confrontation, reconciliation, or
imaginative images, and partly because in any other ways of dealing with what comes up in the
case he believed that simply uncovering and imagery. The theory behind the technique is that
analyzing traumatic memories would only be the material elicited will symbolize important
useful if accompanied by a wish to use these areas of conflict in the person's life. Once again
discoveries as a basis for changing things in the the imaginary material is evoked following a
present. This second notion would be agreeable period of relaxation in a darkened room.
to cognitive therapists working in the 1990s. Assagioli (1965) has used symbolic visualiza-
Bowlby (1985) criticised analysts for steering tion as part of the therapy in psychosynthesis.
away from work on early memories, recognizing The patient closes their eyes and relaxes, and is
that recovery of a traumatic memory can allow then asked to dwell on symbols of integration
distorted schemas to be recognized and re- and balance, of harmony in relationships, of the
structured. Arieti (1985) reformulated the masculine and the feminine, and of affective
Freudian approach, and based his new ap- states. Focusing on particular symbols in this
proach on a cognitive developmental model. way is supposed to bring about increased
The techniques in use in the 1990s in cognitive control in the inner and outer life. Sometimes
therapy will be described below. it is suggested that the patient should transform
Jung gave great importance to the use of the image, so that, for example, a seed becomes a
symbolic or imaginative images in therapy. He tree, or a worm becomes a butterfly.
believed that images are often archetypal in Other therapists have emphasized the im-
nature, and that there is a universal language of portance of interacting with the elements of the
symbols, common across different cultures and imaginative image. For example, Gestalt thera-
periods of history. Jung wrote that he attempted pists (Perls, 1971; Stevens 1971), working with
to translate emotions into images, to find the an image or daydream of an imaginary scene,
images which were concealed in the emotions. would suggest to the patient that they imagine
He felt that if emotion-laden images were left in themselves as each of the other characters in the
the unconscious they could give rise to neurotic image, and even as an animal, or an inanimate
symptoms, but the more they could be brought object, such as the stick which is beating a dog.
into consciousness the calmer the person would In this way different perspectives are developed
become. Jung developed a technique called which may be useful in therapy.
active imagination, during which the person is Before the sections on working with images in
asked to meditate, remaining free of any goal. behavioral and cognitive therapies a brief
They then invite images to appear, and watch outline of phenomenology in the realm of
them without intervening. It is also possible to imagery is provided. This is biased towards a
talk to the images, or to question them. study of imagery in neurotic disorders, but is
Subsequently these visualizations are discussed worth noting that a great deal of work has been
with the therapist. This technique is more likely done on imagery in other fields, notably in
to evoke imaginative rather than memory physical medicine and in sports psychology.
images. Many of the images symbolize aspects
of personal growth. Jung felt that simply
bringing images to awareness and reflecting 6.14.3 TYPES OF IMAGES IN
on them could be therapeutic, as Freud PSYCHOLOGICAL DISORDERS
originally believed would be the case with
memory images. The literature suggests that images abound in
Imaginative images have been used in a psychological states, perhaps particularly in
variety of other therapies. Many of these have anxiety disorders. Ottaviani and Beck (1987)
been more directive in their approach than Jung. revealed that images are common in people with
The content of the image may be specified to panic disorder, and frequent themes are those of
Types of Images in Psychological Disorders 305
physical and mental catastrophe, as is typical of obsessions are not acted upon; and (iv)
their anxious thoughts. Beck et al. (1974) looked disruptive images, which can interrupt compul-
at ideational components in anxiety neurosis, sive rituals, and make it seem imperative to start
and found themes to do with danger, both them again. The most interesting distinction
physical and psychosocial, in the thoughts and here is probably the observation that images
images collected. have different functions, some constituting
Images in phobias have been studied by obsessions (i.e., unwanted, intrusive images),
several authors. Watts, Sharrock, and Trezise and some being covert compulsions or rituals
(1986) hypothesized that phobics would have (i.e., images which are deliberately formed; see
imagery connected with their phobias that was also Salkovskis & Westbrook, 1989). This
relatively lacking in detail and elaboration. highlights the observation that some images
They discovered in a study of visual imagery of are seen as threatening or likely to lead to
coping with a spider that the accounts of harmful consequences, whilst some are seen as
phobics were briefer and less elaborated, capable of warding off harm.
suggesting a lack of coping imagery. However, Wells and Hackmann (1993) looked at images
in another study of stimulus imagery immedi- in health anxiety, and found that they contained
ately following exposure, phobic subjects re- a wealth of information. As with automatic
ported being more aware of the image, but did thoughts (Warwick & Salkovskis, 1990) the
not report less detail (as predicted). This was themes expressed were those of misinterpreta-
surprising in view of a previous study by Watts, tion of bodily sensations and symptoms, and
Trezise, and Sharrock (1986) in which poor overestimation of the likelihood of illness or
recognition memory for phobic stimuli was death. However, the images also began to
demonstrated and taken as evidence for poorly answer the question of what is so particularly
elaborated stimulus processing. bad about such calamities for people with health
Beck (1976) reported on his studies of the anxiety. For many the real calamity lay in the
content of dreams and other ideational material interpersonal consequences of illness or death
in people suffering with depression. These (see Section 6.14.5). Like obsessional patients
dreams reflect themes of defeat, defectiveness, these individuals also had many superstitious or
thwarting, and deprivation, rather than the metaphysical beliefs, often involving fears that
themes predicted by psychoanalysis, to do with thinking in a particular way, or having certain
hostility turned inwards. It was this work, an images, could affect the future, or tempt
unsuccessful attempt to provide empirical providence. For example, some individuals fear
support for psychodynamic views on depres- that imagining death or illness could make it
sion, which led to the development of the happen, or thinking of how lucky they are to be
cognitive model of depression. There are several well, or picturing a happy future, could invite
studies on the themes in depressive dreams disaster. Sometimes the belief is like the popular
(Beck & Hurvich, 1959; Beck & Ward, 1961), view that negative thinking is bad for the
but less has been written about depressive immune system, but more frequently the
images. Layden (personal communication) also mechanism is thought to be God or Fate. These
suggests that depression is characterized by a ideas lead to attempts to control or neutralise
lack of positive images, particularly of the images, in ways which may well exacerbate the
future, which might, if they existed, have the problem, since suppressing thoughts and images
power to motivate the depressed individual to often leads to an increase in intrusions.
work towards realizing this hoped for vision. In generalized anxiety disorder patients
De Silva (1986) has studied images in complain about worrying. Worry has been
obsessive-compulsive disorder. He found, like defined as consisting of long chains of negative
the authors above, that in general the images thought that are predominantly verbal in form,
were not different in content from other and aimed at problem solving (Borkovec,
obsessional cognitions. The most common Robinson, Pruzinsky, & DePree, 1983). Borko-
themes were those of death and decay, illness vec and Inz (1990) have suggested that the
and injury, violence and disaster, and sex and predominantly verbal activity of worrying
blasphemy. He distinguishes between four diverts attention away from imaginal activity
different types of image: (i) obsessional ones, which is more closely linked to the activation of
which are unwanted and intrusive; (ii) compul- physiological arousal. Furthermore, they also
sive images, which are formed deliberately to suggest this may block exposure to it and lead to
neutralize an obsessional image, (which can be symptoms of failed emotional processing,
corrective versions of the original, or indepen- including more intrusions of imaginal material.
dent images bearing no relation to the obses- Where there is imaginal material typical themes
sional one they are meant to neutralize); (iii) are of psychosocial or physical danger (see Beck
disaster images, of what might happen if the et al., 1974).
Wells, Ahmed, and Clark (1995) have also Hackmann, 1993). It has also been reported that
studied images in social phobics. Here, the in depression individuals often have intrusive
finding was that the images of social phobics memories, linked to their current mood, of
when deliberately generated depicted the self, childhood traumas (Brewin, Hunter, Carroll, &
seen in a distorted way, and as if seen from an Tata, 1996; Kuyken & Brewin, 1994; Spenceley
external perspective. Thus, a social phobic tends & Jerrom, 1997). This suggests that some images
to see themself as they imagine others might, may have more than a passing resemblance to
with a bright red or sweaty face, or with shaking reliving experiences in PTSD.
hands or a childish appearance. This also Images in PTSD tend to appear like flash-
happens in spontaneous images social phobics backs, often to scenes which have been
get in naturalistic situations (Hackmann, Sur- especially traumatic. Some of them are so vivid
awy, & Clark, 1998). Here the images are usually that it is as if the patient is reliving the trauma, in
visual ones, but are sometimes sensory impres- rich sensory detail, as if it were happening again.
sions rather than visual images. However, they Often the intrusions people get spontaneously
are still perceived from an external view-point, are always of the same fragment (or fragments)
in contrast with the images less socially anxious of memory. One patient always saw the head-
people get when anxious in a social situation. lights of a car approaching her head-on, on the
These images are often recurrent, and depict the wrong side of the road. It was the headlights
individual in an embarrassing or humiliating which she always saw when waking up in terror
predicament, with some awareness of an in the night, or when lying on the sofa and
audience. When asked when in their lives they looking at the corner into which she had gazed
first remember feeling that way a specific as she spent weeks lying down, recovering from
incident is often recalled, in which they were the accident. Often it appears that the fragments
criticised or bullied (Hackmann & Clark, in which intrude are those which have not been
press). Images in social phobia have an resolved in the mind of the patient. For example,
important part to play in maintaining the the patient who described the headlights on the
disorder, in that like the images in other wrong side of the road linked to the idea that she
disorders they tend to be regarded as reflecting might have been able to prevent the accident.
reality, and therefore they are often acted upon, Revisiting the scene of the accident helped her to
giving rise to avoidant behaviours. They also realize that there was nothing she could have
form part of the postmortem, in which a done, upon which the intrusions decreased
negative, ruminative going over of past ima- markedly. Nightmares in PTSD often involve
gined and predicted future failures leads to a set a total and accurate replay of the traumatic
of exaggerated and distorted images and events. For example, someone who was
memories and images, with a consequent attacked whilst recovering from surgery repeat-
enhancement of anxiety (Clark & Wells, 1995). edly dreamed that she saw the hands of the
Agoraphobics often have recurrent images hospital clock pointing to 10 minutes to three,
(Hackmann & Surawy, in press). In these the then experienced the attack again, and woke at
patients image themselves from an external exactly three a.m., the time at which the attack
viewpoint, experiencing the sort of physical or ended and she was safe again.
mental calamities feared by panic disorder As mentioned above, images in PTSD can
patients. However, in their images they also involve any of the senses. The first patient
see an interpersonal context in which the events described above was able to actually hear the
are occurring. Typically they are either ignored crunch of metal, smell the petrol and taste it, see
and experience themselves as far from home or the steam rising, and feel the actual impact.
help, or they attract unwelcome attention, Imagining the crash gave her pain in her chest
which is embarrassing, and may also have the and neck, which had been hurt in the crash a
effect of making it harder for them to reach the year before. Sometimes these flashbacks are not
safety of home. For example, someone might completely veridical memories. For example,
picture themself being taken to hospital and the same patient had been told that since the
kept there against their will, whist another might man who crashed into her was foreign he could
see themself lost and alone in an unreal world, not be prevented from coming back in the future
where it has become impossible to reach home. and hiring another car. At one point this was
In therapy with patients suffering from a represented in an image of him crashing into her
variety of anxiety disorders it has been noted again in the future, and walking up to talk to her
that there is often close similarity between the in a way that had not happened in the real
sensory and interpersonal content of recurrent accident. She took this to mean that this was
images and upsetting childhood memories what would really happen in the future. Similar
(Hackmann, 1995; Hackmann & Clark, in features are noted after sexual abuseÐthere is
press; Hackmann & Surawy, in press; Wells & reliving, not only in the visual modality, but also
Working with Images in Behavior Therapy 307
of sounds, tastes, smells, and sensations, and questioned, by Breger and McGaugh (1965).
there can be mixture of images and memories. Singer and Pope (1978) conclude that therapy
There is also often fear in both disorders that seems to work by changing the client's antici-
letting these mental contents into full awareness pations, self-communications, and images with
could have serious mental or physical con- respect to the feared situations. The mechanism
sequences. Once again this leads to attempts to remains to be fully investigated.
suppress such intrusions, which can then
perpetuate the problem.
6.14.4.2 Covert Conditioning
6.14.4 WORKING WITH IMAGES IN Cautela (1977) produced a useful review of
BEHAVIOR THERAPY the assumptions and procedures in covert
6.14.4.1 Desensitization conditioning, in which it was conceptualized
in operant-conditioning terms. The main as-
In 1958, Wolpe published his famous book sumption was that behavior patterns could be
about desensitization. This was based on strengthened or weakened by imagining them to
experiments on the counter-conditioning of be followed by either positive or negative
fear responses in laboratory animals through reinforcement, or by punishment, or by an
the pairing of stimuli which had been paired absence of the previous reinforcers. This was
previously with noxious stimuli with positive not the original way in which covert sensitiza-
stimuli (e.g., Masserman's experiments with tion was conceptualized (Cautela, 1967), when it
cats). Wolpe called the process ªreciprocal was seen more as a classical conditioning
inhibition,º and paired the feared stimuli with procedure, in which the objective to was the
relaxation, or with eating, or sexual stimuli. opposite from that of desensitization, in that the
This process, when repeated a number of times, aim was to render a previously positive stimulus
appeared to decrease the amount of fear evoked noxious, by pairing it with imaginal stimuli
by the negative stimulus, and increase the which are aversive, and thus decrease the chance
amount of approach behavior. The feared that presenting the original stimulus will lead to
stimuli were approached in a graded way, via undesired behaviors. By 1977 the procedure was
a carefully arranged hierarchy of feared situa- considered to work best if the maladaptive
tions. Wolpe discovered that imaginal presenta- behavior was imagined after the triggering
tion of stimuli was easier to organize than in vivo stimulus, and then followed by negative con-
presentation, and also that the most practical sequences. Self-control or relief scenes were also
activity to pair with the stimulus was relaxation. added, and alternated with aversive scenes. A
Results with this method were very impressive, relief scene might involve having the temptation
and in 1977 Smith and Glass concluded that to carry out an undesirable behavior, but
desensitization-type behavior therapies pro- starting to feel ill, then deciding to resist the
duced larger average therapeutic effects than temptation, and then feeling immediately better,
any other type of psychotherapy, at that time, and proud to have resisted it.
particularly in the treatment of phobias. The most extensive use of such techniques has
Yet the important ingredients in the proce- been by Cautela, and in a series of papers he has
dure remain uncertain. The use of a systematic reported its use in the treatment of many
hierarchy and progressive relaxation of the maladaptive approach behaviors, such as
muscles have been shown not to be essential smoking, drinking, obesity, compulsive steal-
(Dawson & McMurray, 1978). Wilkins (1971) ing, and deviant sexual behaviors (Cautela,
found that the research literature seemed to 1966, 1967, 1971). Cautela has developed a set
indicate that the significant ingredient of of graphic and disgusting images, which can be
systematic desensitization and similar treat- used as they are, or elaborated with the patient.
ments is the use of imagery by the client. These are paired with mental images of the
Weitzman (1967) interviewed patients after desired stimulus or maladaptive behavior. For
every session of desensitization. He found that example, a patient might be asked to imagine a
during the period of silence in which the client desired sexual partner in a disgustingly filthy
held the image the experience was not a static cellar, which causes the patient to vomit (in
one. Other images and associations tended to imagination) all over himself and the desirable
occur, and the image at the end of the period had partner. The disgusting scene is terminated by
often undergone some changes. Also, those who his escape from the cellar, and the other
observed Wolpe conducting the therapy under- individual. It is interesting to note that in many
scored the process of cognitive exploration and studies of covert sensitization progressive
discussion which occurred. The relationship of relaxation is used, not for the purpose of
this approach to learning theory has been reciprocal inhibition, but to enhance the
generation of vigorous imagery, or stronger defensive if it reduces anxiety, and is conse-

emotional reactions. Covert response cost has quently reinforced.
also been described by Cautela (1970a). In this Stampfl theorized that these neurotic defen-
case the removal of an imagined positive sive behaviors could be unlearned if something
reinforcer is contingent on a real or (more very similar to the original trauma could be
usually) imagined response, which can be either strongly recreated, in the absence of any real
a maladaptive approach or avoidance response. punishment, deprivation, and so on. The use of
This technique is relatively untested. imaginal material proved a convenient vehicle
Covert positive reinforcement has also been for this, as the patient was often able to evoke the
used by Cautela (1970b). In this procedure the visual cues, and the therapist could provide
person rewards himself in imagination for the suitable sound effects. It was hypothesized that
desired behavior in real life or in imagination. this process of play-acting the fears, and reliving
Covert-positive reinforcement can be used to the trauma could lead to the extinction of
reinforce both approach and avoidance beha- anxiety. Thus, the theory spanned psycho-
viors. It is considered to be an operant analytic and learning theory ideas about anxiety.
procedure in which a covert reinforcer is used The first research study was by Hogan (1966).
to increase probability. It need not involve In it psychotics were given either implosive or
relaxation or hierarchical presentation of ma- more traditional psychotherapy. There was a
terial, so it differs in a number of respects from significant difference between the two groups,
desensitization. with more of the implosive therapy patients
Cautela also describes a process he calls being discharged after one year. Levis and
covert extinction, in which the client is asked to Carrera (1967) reported on the effects of 10
imagine himself carrying out the behavior he hours of implosive therapy in neurotic patients,
wishes to curtail, without it bringing any of the with a significant difference in two of the 16
usual satisfactions. For example, a smoker MMPI scales compared with control groups. In
might imagine himself smoking without being a second study, Hogan and Kirchner (1967)
able to taste or smell the cigarette, and without studied rat phobics. Those in the implosive
any decrease in his level of stress. Cautela (1971) group were significantly more likely to pick up a
reports a few studies where these techniques rat in the behavior test than those who had been
were used successfully, and also warns of several given only pleasant imagery. Hogan and
aspects of treatment which the therapist and Kirchner (1968) also reported a successful
patient need to be aware of. Finally, Cautela one-session intervention with snake phobics.
describes covert modeling, in which the learning In another study, Kirchner and Hogan (1966)
or alteration of new behaviors is effected by administered the implosive therapy standar-
imagining others carrying out the behavior, and dized tape simultaneously to a group of rat
observing the imagined consequences. A shap- phobics in a single session, and played music on
ing process can also be used, where the patient a standardized tape to the control group. The
first imagines observing someone else carry out implosive group were superior to the control
the behavior, then watches themself do it, then group in their willingness to pick up a rat. It is
imagines actually doing it, and finally carries it interesting that these results were obtained with
out. There is experimental evidence to support such standardized material, in view of the
the idea that this is a useful technique (Cautela, original theory behind implosion, which aimed
1977; Kazdin 1974). to extinguish the anxiety reaction to highly
idiosyncratic sensory cues present at the time of
the supposed original trauma. This suggests that
6.14.4.3 Implosion and Imaginal Flooding the psychodynamic aspects of the theory may be
redundant.
This technique attracted considerable atten- However, it is also worth noting that Levis
tion in the 1960s, following a theoretical paper (1980) remarks that one of the most interesting
by Stampfl and Levis (1967). Stampfl viewed the phenomena to occur with the use of implosion
defense mechanisms of the neurotic as avoid- therapy is the apparent reactivation or redinte-
ance responses which had been learned and gration of early memories during or following
perpetuated because they reduced anxiety. the presentation of imaginal scenes depicting the
Originally the patient, often when very young, most feared outcomes possible in an individual's
has traumatic experiences, in which they has feared situations. The emergence of this new
been rejected, humiliated, deprived, or pun- material helps shape the course of new imaginal
ished. Subsequently everything associated with sessions, and is thought to provide a closer
these events, such as the sights, sounds, and approximation of the avoided conditioned
smells, elicit anxiety, and these cues motivate stimulus complex from which one is attempting
behavior. This behavior can be considered to extinguish anxiety. Several examples are
Working with Images in Behavior Therapy 309
provided in this chapter of the reemergence of results in the accounts becoming less fragmen-
traumatic early memories during therapy, and ted, more organized (i.e., indicating more
an example of the same phenomenon is attempts to understand the traumatic events),
described with reference to implosion therapy more complete, longer, and richer in thoughts
for a recuurent nightmare. and emotions, but with less detail about the
In the 1970s there were several studies events themselves (Foa et al., 1995). Overall this
comparing imaginal flooding with other beha- procedure also produces good symptomatic
vioral treatments. For fearful volunteers and relief in real life. Also, there was greatest change
simple phobics in vivo exposure treatment in indices of fragmentation and organization in
generated better results than imaginal proce- the narratives of those who improved the most.
dures (Bandura, Blanchard, & Ritter, 1969; These results are in line with Foa's theoretical
Barlow, Leitenberg, Agras, & Wincze, 1969; position, that PTSD may occur in cases where
Dyckman & Cowan, 1978; Mathews, 1978; there has been inadequate emotional proces-
Sherman, 1972). With obsessive compulsives sing, possibly because the terrible memories
both media produce similar outcomes (Foa et al., have somehow been held out of awareness (Foa
1985; Rabavilas, Boulougouris, & Stelanis, & Kozac, 1986). Jaycox and Foa (1996) discuss
1976). With agoraphobics two studies indicate possible obstacles in implementing exposure
the superiority of in vivo exposure (Emmelkamp therapy in certain cases of PTSD. These include
& Wessells, 1975; Stern & Marks, 1973) and two extreme anger, emotional numbing, and over-
studies indicate equivalent gains (Chambless & whelming anxiety. Practical suggestions are
Goldstein, 1982; Mathews et al., 1976). made, such as projecting the imagery on to an
Foa, Steketee, Turner, and Fischer (1980) imaginary wall, and ªzooming outº from the
looked more closely at this with a group of images if the distress of the client becomes
obsessive compulsives with checking rituals. In extreme, to the point where the sense of current
addition to their feared situations which they reality is about to be lost.
were exposed to in vivo, they also had disaster It remains to be seen whether the results of
fears for the future which could only be reliving treatment can be improved upon by
presented in imagination. Half the subjects giving the intervention a more complex ratio-
received two hours of in vivo exposure only. nale, and tackling some of the issues raised by
The other half received only half an hour of using techniques such as those derived from
exposure, with 90 minutes of imaginal exposure cognitive therapy to challenge distorted ideas
to the feared disasters. Both groups improved about the trauma itself, or its psychological
significantly, to the same degree. However, the sequelae.
group that received the combined treatment
retained their gains, whilst some relapse was
evident in the in vivo only group, suggesting that 6.14.4.5 Eye Movement Desensitization and
more of the elements of the fear structures (Foa Reliving
& Kozac, 1986) were addressed in the imaginal
exposure than in the in vivo exposure group, Shapiro (1989) published details of a new
leading to more successful emotional processing. treatment for PTSD, which she called eye
movement desensitization and reliving
(EMDR). Subsequently she has also published
6.14.4.4 Reliving Treatment in Post-traumatic a book (Shapiro, 1995) on the subject. The
Stress Disorder therapeutic technique was described as invol-
ving eliciting from the client sequences of large-
A technique which has proved relatively magnitude, rhythmic saccadic eye movements,
successful in the treatment of PTSD is that of while holding in the mind the most salient
repeated imaginal reliving of the trauma (Foa et elements of a traumatic memory. The client is
al, 1991). After preparation and socialization as asked to come up with a prototypical image
to the treatment rationale clients are asked to which symbolizes the area of trauma. After
repeatedly relive their traumatic experiences, being subjected to a set number of eye move-
describing them aloud, in the first person, and ments they are encouraged to talk about what
attempting to reexperience exactly what hap- remains of their concerns, and what has come
pened to them. Particular attention is paid to the up for them during this brief period of time.
hot spots, that is, the most emotionally laden When they come to the end of discussing this a
parts of the memory. Clients are asked to take fresh image is evoked, symbolizing the imaginal
home tape-recordings of these sessions, and or verbal material which has emerged. The
listen to them daily if possible. This procedure process is then repeated until the client reports a
frequently results in a decrease in the associated significant reduction in the subjective units of
affect, particularly the emotion of fear. It also distress (SUDS). This appears to result in rapid
reduction in anxiety, changes in cognitive an imaginal exposure approach or a thought

assessment of the memory, and cessation of stopping approach was relevant one would need
flashbacks, intrusive thoughts, and sleep dis- a functional analysis of the cognitions con-
turbance. In her book Shapiro writes about cerned to decide which strategies were appro-
what she calls accelerated emotional processing, priate for which parts of the problem.
and there is some resonance with the work of
Foa's group, described in the previous section.
It is also interesting to recall that in Wolpe's 6.14.5 WORKING WITH IMAGES IN
work (described in the section on desensitiza- COGNITIVE THERAPY
tion) merely bringing upsetting images to mind, 6.14.5.1 Images and Memories in Cognitive
and holding them in awareness, tended to alter Therapy
both their content and their meaning, with a
subsequent drop in affect. Internal reality is said by Beck (1976) to
However, the literature suggests that EMDR comprise meanings, significances, and imagery,
is a far from uncontroversial area. There are a and we are advised to work both with images and
number of review articles pointing out that many thoughts. Sometimes in therapy an image seems
of the studies reported are characterized by to resonate more fully with an expressed emotion
serious methodological flaws, including failure than the thought expressed in words. For
to use repeated objective measures, and the use of example, the anxiety of an agoraphobic who
other interventions in combination with EMDR thinks that they might fall down makes more
(Acierno et al., 1994; Lohr, Kleinkrecht, Tolin, sense to us when they describe an image of this
& Barrett, 1995). Nevertheless, there are many fall, in which they see a crowd gather, summon
reports of rapid improvement with this techni- an ambulance and take the patient to hospital,
que, particularly where there are disturbing where they are kept against their will. This type
memories, and a recent meta-analysis found as of difference between the first negative auto-
much evidence to support this technique as there matic thoughts reported in a situation, and the
is for other efficacious approaches to PTSD (Van spontaneous images which are described, has
Etten & Taylor, 1997). Research questions which been exemplified in a paper by Wells and
remain to be answered decisively include Hackmann (1993). In this paper the negative
whether or not the rapid eye movements are a automatic thoughts and images about illness and
necessary component, whether or not relaxation death were studied in a group of hypochon-
facilitates the process, and whether any addi- driacs, and material presented highlights the
tional benefit is gained above merely repeating extra, idiosyncratic layers of meaning depicted in
the presentation of the image. the images. It is clear that for many hypochon-
driacs the feared catastrophe is not just illness or
death, but the imagined interpersonal cost to
6.14.4.6 Thought Stopping them of these events (such as being neglected in
hospital by relatives, or dying and ending up in
It might appear that therapeutic strategies in Hell, or alone or trapped in a coffin with full
which the patients are directed to immerse awareness, or being able to witness one's family,
themselves in fearful imaginings, or relive carrying on quite happily without one).
distressing memories, would be in direct contra- Thus, attending to the content of images can
diction of an approach like thought stopping, help people get a ªhandleº on why they are
which aims to suppress thoughts or images. getting upset (see Gendlin, 1988) and can also
However, this approach was used for a number provide a quicker route in to what Barnard and
of years, and was sometimes considered useful Teasdale (1991) would call the implicational
in the treatment of obsessions and other level of meaning which tends to be more poetic
unwanted thoughts and impulses. and more idiosyncratic than the less colorful,
Thought stopping has been another contro- shared level of propositional meaning. It is also
versial technique, with some review articles true that, as Lang (1977) points out, images
sounding a cautionary note. Where there have contain both stimulus and response elements,
been positive results the emphasis has not been and thus give access to more of any particular
on blocking the obsessional cognitions as such, fear structure. Of course, when working with
but on stopping before attempts to covertly verbal material in cognitive therapy we can
neutralize the upsetting thoughts or images can access more meaning of a more idiosyncratic
occur. Thus, as a behavioral strategy the best nature with judicious use of questions such as
use of thought stopping would be in the area of ªWhat did that mean to you?,º ªWhat was the
response prevention, that is, the prevention of worst thing about that?,º and ªCan you tell me a
covert rituals (Salkovskis & Westbrook, 1989). bit more about that?º These are the type of
This would mean that in order to decide whether questions used in the ªdownward arrowº
Working with Images in Cognitive Therapy 311
technique (e.g., Greenberger & Padesky, 1995), draped across the coffin, whilst her family were
which is a standard technique in cognitive grouped around it. This was a cue for her
therapy to elicit the full meaning of the appraisal therapist to enquire whether she was picturing
leading to the strong emotions reported in this at the time, which she was. This then led her
therapy. What is being suggested here is that say that she was, but that she habitually tried to
spontaneous images accompanied by high affect suppress this image, as she feared that if she
can be a rapid way into the system. pictured it this would make it more likely to
In cognitive therapy there are a number of happen. This type of information is also useful
aspects of imagery one might choose to work for the therapist, as it is possible that her
on. These include unpacking the meaning voluntary efforts to suppress the image are
encapsulated in the image, attempting to likely to make it recur more frequently, thus
transform it, and examining and working on maintaining her distress, as in thought suppres-
beliefs about the meaning of actually having the sion experiments (Trinder & Salkovskis, 1993).
image. It is also possible to work on memories, It is also important in some disorders, such as
which are imaged by the patient when asked to obsessions, to enquire about the existence of
relive the remembered experience. Once again neutralising images. Sometimes these have the
the meaning given to the memory can be function of compulsions, in that they are evoked
explored, and sometimes transformed using voluntarily in order to neutralize unwanted
imagery techniques. obsessional intrusive thoughts. For example,
someone who had a spontaneous image of her
husband being ill might deliberately try to form
6.14.5.2 Eliciting Images and their Meanings a positive image of him looking healthy and
well. Such different functions and origins of the
Greenberger and Padesky (1995) advocate images have to be taken into account when
staying with questioning and careful reflection planning a strategy, whether the treatment is a
until cognitions arise which seem to be an cognitive or a behavioral one.
adequate match for the level of emotion Images are common in PTSD. In this case
experienced. They pose a series of useful they are frequently fragments of disturbing
questions such as ªWhat does this mean about memories, which press into conscious awareness
me, my life, other people, the future?,º ªWhat at frequent intervals, to the distress of the
am I afraid of?,º ªWhat might happen?,º ªWhat individual. Whilst they are usually closely
images and memories do I have in this situa- related to the trauma they are not always
tion?º Whilst doing this visual images or sensory identical to it. For example, one man was
impressions can occur in any modality, reflecting traumatized by having to witness the body of a
the present, the past, or the future, and these can woman who had had her head chopped off. He
be literal or metaphorical images. Any of these had recurrent images of her husband swinging
images can be used in cognitive therapy, in the the chopper towards her, which he had not
sorts of ways described in subsequent sections. actually seen. However, the image seemed to
It is also possible to enquire directly about the have input from an earlier, linked memory of
presence of an image. For example, in agor- seeing his father attack his mother with
aphobia clients are often rather vague about the chopping movements when he was a boy. The
feared catastrophic consequences of their bodily image of the murder was accompanied by the
symptoms of anxiety, whilst their avoidant sense that he should have been able to prevent it,
behavior suggests that they are quite frightened. an inappropriate response since he was not
Asking them whether they had a picture of what there, nor did he know the people. However, the
might happen in a given situation often provides response was identical to the way he had felt as a
graphic information about the exact nature of boy. Images which appear to be fragments of
the feared catastrophes. For example, one memory, or which appear to have much input
person might picture themselves as having from memory in sensory modalities are often
collapsed in a crowded place, and being totally triggered by sensory cues, which incidentally
ignored, whilst another might have an image of can also sometimes trigger the distress without
a large crowd gathering and an ambulance the patient consciously remembering the origi-
arriving with a wailing siren. nal event. This brings us back to the starting
Sometimes it is possible to spot when a client point of allowing enough time for the patient to
has a spontaneous image whilst describing stay with the strong emotion evoked, for any
something from the way they point, gesture, associated thoughts, images, and memories to
or direct their gaze. One woman with hypo- come into awareness. Needless to say this can
chondriasis was describing what she thought temporarily increase affect as meaning is
would happen when she was dead, and indicated accessed, and may be resisted at times by
with her hands how her Elvis flag would be patients.
It is also important to note that images which to work on early memories using imagery
seem in fact fragments of upsetting memories, or techniques such as those described below, often
amalgamations of several of them, are also with profound results.
present in other Axis I disorders (Hackmann, As mentioned above, some of the images
1995; Hackmann & Clark, in press; Hackmann clients bring are symbolic rather than literal
& Surawy, in press; Wells & Hackmann, 1993). images. For example, someone feeling ex-
Other authors have also noted the intrusion of hausted and resentful about the way in which
traumatic memories during depressive episodes their family depends on them may picture
(Brewin, Hunter, Carroll, & Tata, 1996; Kuyken themself with their family in a canoe, having to
& Brewin, 1994). row them all upstream in the Amazon. Similar
Once images have been elicited the therapist questions can be used to explore the meaning of
needs to help the patient understand the this type of image, and its possible history in the
meaning attached to them. Images can be life of the individual, before proceeding to
considered at the level of automatic thoughts, consider ways of transforming its meaning
in which case the therapist can ask what the (Edwards, 1989). This work considers thematic
image means to the person, what has led up to rather than symbolic content of the images or
the events in the image, and what is the worst dreams being presented, in the sense that the
thing about it. Typically this sort of question client provides their own hunches about the
will give rise to a set of negative automatic history and meanings of the images, rather than
thoughts, which can be worked on using verbal the therapist trying to interpret them in the light
techniques, or imagery techniques as described of what the therapist might consider to be the
below. It is also important to find out what sort usual symbolic meanings (Freeman, 1981).
of beliefs the patient has about actually having
the image. For example, do they see it as a
prediction of what will happen in the future, or 6.14.5.3 Transforming Images and their
do they think that such images can affect reality Meanings
in some way? If so, such beliefs may also need to
be worked on in therapy. The meanings elicited from consideration of
Further questions about what the image the image can be worked on using the full range
means about the individual, other people, and of verbal techniques and behavioral experi-
the world in a more general way can lead on to ments familiar to the cognitive therapist. The
the elicitation of conditional and unconditional encapsulated meanings can also be changed by
core beliefs, which can also be worked upon at a altering the image in the modality or modalities
later stage. in which it was experienced. A short summary of
Once all the meaning and sensory data in the possible interventions to transform images and
image has been unpacked a useful bridge can be their meanings at the level of negative automatic
made back to early experience by asking when in thoughts will now be given.
life the client can first remember having the In many anxious images a scenario is pictured,
types of thoughts and feelings and sensory in which the worst possible outcome has been
experiences reflected in the image under con- visualized, and the image is effectively frozen in
sideration. Often this takes the patient right time at this worst point. In such a case it may be
back to traumatic memories from childhood sufficient to simply let the image run on in time.
which appear to have set the scene for later For example, a client who was afraid of being
maladaptive schemas (e.g., Wells & Hackmann, sick on arrival at a party, and thus totally ruining
1993). For example, a patient with an obses- the evening for everyone, was helped by running
sional fear of getting AIDS repeatedly visua- his recurrent image on in time past the point
lized himself in hospital, in a white, cast-iron where it usually stopped (i.e., when he had just
bed, all alone because he is blamed by others for vomited) to discover that as it unfolded people
contracting the disease. In the patient's mind appeared in the image to help him clear up, were
there was a direct link between this recurrent sympathetic, and encouraged him to stay on
image and a memory of lying in hospital with a until he felt better. Thus, he could appreciate the
broken arm, alone and not aware of the pain so fact that the evening might not in fact be ruined.
much as the fear of his father blaming and This was easier to believe once he had also tried
rejecting him for having had an accident. To his picturing what might happen if his girlfriend
amazement he realized that the bed in the vomited, rather than him (a decentring techni-
hospital in the image and in the memory was in que which is often useful in social anxiety).
fact the identical white, cast-iron bed with the Another client was terribly distressed by
same white sheets and blankets. Having located recurrent images of her own gravestone, and
significant memories in this way (or if they come the happy faces of her husband and child when
up spontaneously in therapy) it is then possible they visited it. Verbal discussion had helped her
Working with Images in Cognitive Therapy 313
to see that this image was only an image, and did snags arise in the imaginary scenario more
not necessarily depict what would happen in the verbal discussion and imagery work can be done
future, but without lessening her distress. What to deal with these.
did help was to imagine herself alive and well, Another useful technique is to abandon the
and looking at this image on a television. She spectator position. In social phobia it has
was then able to picture herself switching off the already been mentioned that individuals are
television, and driving away from the house. likely to have very distorted images of them-
This changed her beliefs about the meaning of selves, as seen from an external point of view
having the image, in the sense that she no longer (i.e., as an observer might see them). Since these
felt that it reflected her future, but was only a images can be shown to be inaccurate, using
product of her fearful mind. This simple feedback from others, or video feedback,
intervention got rid of both images and night- patients can be advised to ignore them, and
mares on this theme, which had been torment- focus instead on the external environment, and
ing her. Putting the image on the screen gave her the true reactions of others. In a similar way
the message that after all it was only an image, people with health anxiety can have images of
and one which she could control. This maneuver what they imagine is happening inside their
is also useful in dealing with any very frighten- bodies, and can learn to ignore these or replace
ing imaginal material, since the image can then them with more realistic mental pictures.
be switched on or off, or made smaller or
dimmer, as a prelude to dealing with it further.
In these cases the meaning that is changed is at a 6.14.5.4 Working with Beliefs about Having
meta-level: what is changed is the meaning of Images, Intrusive Memories, and
having the image, rather than the meaning of the Nightmares
image. Similar techniques can be used in the
Often patients who experience affectively
treatment of distressing images following trau-
laden intrusions are further distressed about
ma. Putting an image or vivid memory of a
the meaning of actually having the intrusions.
screen and altering it can help keep affect at a
They may believe that these intrusions reflect
managable level, and reinforce the idea that
reality, for example, that they foretell the future.
what happens in that working space is not what
Or they may believe that they are a sign that they
is happening in the present: it is only an image or
are losing control or going mad, particularly if
memory, and belongs in the past. Further work
attempts to banish them lead to increased
can then also be done to change the content if
occurrence of the intrusions. Sometimes they
appropriate.
believe that having particular thoughts or
In some cases when one enquires about
images may mean something bad about them
images those that are reported are not accom-
as a person, or may directly affect what will
panied by much affect, and are rather small, or
happen (e.g., thinking about illness can make
distant, blurred, or foggy. In such a situation the
you become ill, or thinking about being well or
patient can be asked to zoom in on the image,
happy could tempt providence). Such beliefs
and make it bigger or clearer, in order to
can be tackled in therapy using verbal techni-
examine and work on the content.
ques and behavioral experiments.
Where there is an absence of positive images,
for example in the hopeless depressive attempt-
ing to picture the future, it may be helpful to 6.14.5.5 Working with Core Beliefs Using
prompt the patient to generate detailed, positive Imagery Techniques
images. For example, they can be asked to
picture themselves in the future when the A variety of verbal and behavioral techniques
depression is over, and they can be asked to are also available for use in changing core beliefs
picture where they are living, with whom, and (Beck, Emery, & Greenberg, 1985; Beck, Rush,
what work they are doing, and what their Shaw, & Emery, 1979). These can be used to
hobbies are. They are to imagine who is there examine both conditional and unconditional
and what is actually happening at given points beliefs about the self, the world, and other
in time. This type of work can subsequently people. However, there may be ways of
have a motivating effect on the patient (Layden, supporting this verbal work with imaginal
personal communication). material in ways which enhance the emotional
In a similar way where the patient is about to shift, and help to affirm and strengthen more
try some new behavior in real life it can be very adaptive ways of viewing life.
helpful to imagine carrying out the desired The cognitive model of emotional disorder
coping behavior. This gives the opportunity for suggests that our negative automatic contents of
a useful rehearsal of the skill, and can then either consciousness reflect our core beliefs, as
go into memory as a success experience, or if activated by present events. These beliefs were
formed as a result of early experience. Very his parents did love him, and also that back in
often there are particular early memories which the 1950s people did not realize how traumatic a
seem to reflect core beliefs as they emerged in a lonely hospital stay could be for a small child.
person's life. These memories can be accessed This intervention had the effect of abolishing his
and transformed using imagery techniques, as panic attacks for several months, during which
described by Edwards (1990), Layden, New- additional work was done on his core beliefs.
man, Freeman, and Byers Morse (1993), and Quite fanciful scenarios can be utilized to
Smucker, Dancu, Foa, and Niederee (1995). good effect. One patient who had concluded at
Layden et al. (1993) describe the sequence in an early age that she was unlovable after certain
which one can work when attempting to messages were given to her by her mother
ªrepairº traumatic early memories. The first repeatedly saw her child self as unattractive,
step is to notice when a negative core belief is with the word ªprecociousº over her head. In
activated, and instruct the client to dwell on how imagination she visited an ªinner guide,º whom
they feel emotionally, in terms of bodily she visualized as a wizard, and asked him to
sensations, and what sorts of thoughts and show her in a crystal ball what sort of a child she
images they are having. Once they have dwelled actually was. In the crystal ball many pleasant
on these contents of consciousness they are images of herself appeared, including one of
asked whether there is an early memory which is herself aged six putting a hot water bottle in her
linked to such emotions, sensations, and parents' bed. This image had the word ªkindº
thoughts. Very often one or more traumatic over her head, and was accompanied by a deep
memories come to mind. Once a memory has and lasting shifting of the affect associated with
been selected as seemingly important in the memories of her childhood, and her feelings
formation of the negative core belief the patient about herself.
is instructed to close their eyes, and relive the More orthodox schema work can also be
memory, frame by frame, reporting their reinforced by the use of symbolic material. For
experience aloud, and the meanings they are example, one patient had many unconditional
giving to events. Once all the painful meanings negative core beliefs about herself and others, to
have been discussed and challenged where the effect that she was an emotionally deprived
appropriate using verbal techniques it is often person, whom others should look after un-
extremely helpful for the patient to mentally conditionally, and never leave her to fend for
replay the memory, bringing in any corrective herself. If they did it meant that she had been
information which has been pinpointed during rejected and abandoned in a harsh world, and
discussion. This can be done in many ways. For could trust no-one. In therapy she was working
example, the adult self can visit the unhappy towards being able to stand criticism, and take
child, and present an adult perspective on their care of herself without a catastrophic emotional
predicament, and the conclusions they have response. She was greatly supported in this by
drawn from it. Also, other coping and rescue reading the story of Vasalisa, whose mother died
factors can be highlighted. when she was small, but left her a doll who lived
To give an example, a man suffering from in her pocket, and helped her decide what to do
agoraphobia had great anxiety on going far when the going got tough. The patient found
from home, accompanied by fears of becoming this a most useful metaphor for her new sense of
ill in some way and images of being taken to herself as supported, but able to be independent,
hospital, kept there indefinitely against his will, with growing intuition and skills of her own.
and never being visited. Whilst attempting to Finally, it may be worth noting that some of
transform one such image of being trapped in the techniques described above which can be
hospital he retrieved a traumatic memory of used to transform the meaning of early
being taken to hospital when he was three, left memories can also be used when working with
there by his parents for three days without intrusive traumatic fragments of memory. The
explanation of where they had gone. At the time client can be asked to bring the traumatic
he had become extremely afraid that, as the memory vividly to mind, and then unpack its
unwanted fourth son of a poor family with a sick meaning, as described above. Once the meaning
mother, he had been gladly abandoned by his has been discussed and verbally challenged the
parents. The transformation of the meaning of memory can be replayed in imagery, incorpor-
this memory image was effected by having the ating material depicting the new perspective.
adult self visit his parents in the hospital, and For example, a man whose father had died in an
warn them not to leave the child there without explosion discovered that the meaning behind
explaining why they were doing it, and reassur- his intrusive image of his father's body was the
ing him that they loved him. This was idea that his father's spirit had not been able to
accomplished after reviewing through discus- leave the scene of the accident. Imagining his
sion in therapy the evidence he had that in fact father's spirit as now being free, and able to
Conclusion 315
travel to his favorite place and then be released scious, to use the terminology of the analysts.
provided relief, and the images of the body It is certainly true that after a traumatic
disappeared. experience people often try to keep memories at
bay, and the fragmented memories appear to be
6.14.6 CONCLUSION stored in sensory modalities, and can be readily
accessed by situational cues, to the extent that in
Clinical psychologists who work within the PTSD people can find themselves involuntarily
scientist±practitioner tradition would probably reliving various aspects of the trauma. As time
agree on a model of human functioning which goes by (in cases where the problem is
proposes that in a given situation conscious and successfully resolved) a narrative version
unconscious appraisals will be made, leading to emerges, which incorporates details previously
a set of automatic reactions (such as autonomic forgotten, and which is no longer fragmented or
changes and probably some automatic adjust- disjointed. This narrative can be run through in
ments in information processing, together with imagination or conversation without enormous
behavioral reactions (such as escape, avoidance, distress, and the more sensory type of memory is
etc). Both automatic and behavioral reactions less likely to be triggered by sensory cues. This
may change the perceived stimulus situation to interesting process has been described by Jaycox
some extent, so fresh appraiasals may be made. and Foa (1996), and is also consistent with
For example, in a panic attack bodily changes theoretical models such as those of Brewin,
may be perceived, and catastrophically mis- Dalgleish, and Joseph (1996), Dalgleish (1997),
interpreted (perhaps in an image of an imagined Ehlers (1997), Ehlers and Clark (in press), and
heart attack) resulting in an escalation of others discussed by Power (1997).
anxiety. Also, in social anxiety a person might It may be that such theoretical accounts of
talk quickly, and attempt to fill silences for fear PTSD have something to tell us about other
of being thought boring, but might then get a emotional problems. It has been noted above
distorted image of themselves as babbling or that in various anxiety disorders there are
talking terribly quickly, from which they might spontaneous images in anxious situations,
conclude that that is how they are being seen by which not only depict possible catastrophes
others at that moment. which might occur now or in the future, but also
The therapist can attempt to break in to are often rich with sensory and interpersonal
apparently closed systems of situations, apprai- material which appears to be linked to past
sals, and automatic and behavioral reactions in experiences in which there were similar themes
a number of ways. In life people are continually and stimuli. There is evidence that bringing
appraising stimuli for their meanings, and then recurrent upsetting images into full awareness
reacting accordingly. If we agree that this takes can often spontaneously evoke such traumatic
place partly consciously and partly uncon- early memories. Both images and memories
sciously then there need be no disagreement echo current concerns and important themes for
between various schools of thought, but instead the person, encapsulating idiosyncratic mean-
they can be seen to be focusing on different ings, linked to core beliefs.
aspects of functioning. A wide range of techniques are available for
Images and memories with sensory compo- use in this ªworking space,º and they seem to
nents form a sizable proportion of the conscious share many characteristics. They allow rich,
appraisals of many people, and it is also possible multifaceted material to emerge into full
to bring them under voluntary control, at least consciousness, and provide opportunities for
to some extent. Since they can contain both the incorporation of corrective information,
stimulus and response elements (Lang, 1977, and the possibility of moving towards storing
1979) they can provide a useful working space in material in a semantic, orderly form, which does
therapy in which to attempt to change apprai- not intrude, and is not so affectively laden as
sals of stimuli, or of automatic or behavioral when it was stored in a more sensory mode. It is
reactions to them. interesting to note that in a number of the
There is a certain amount of literature to therapeutic approaches described merely bring-
support the view that emotion is more closely ing upsetting images or memories to mind
linked to mental contents with sensory compo- repeatedly seems often to result in spontaneous
nents than those in the verbal modality. In most changes over time, with the imagined material
individuals conscious experience is a rapidly becoming less emotionally charged, less vivid,
changing mix of these two ingredients. It has and less threatening in meaning. In other cases
been hypothesized by Borkovec and Inz (1990) imagery techniques can be used to access
that one of the possible functions of verbal meanings, which can then be challenged using
worrying is to keep more frightening or upsetting verbal discussion techniques, behavioral experi-
images or memories at bay, or in the uncon- ments, and direct restructuring of images and
memories. There also appear to be direct effects Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual
on behavior from the imaginal rehearsal of representation theory of post-traumatic stress disorder.
Psychological Review, 103, 670±686.
possible future scenarios. However, this whole Brewin, C. R., Hunter, E., Carroll, F., & Tata, P. (1996).
area has not been extensively researched, and Intrusive memories in depression: An index of schema
much interesting work remains to be done. activation? Psychological Medicine, 26, 1271±1276.
Brown, R. W. (1958). Words and things. Glencoe, USA:
Free Press.
Buzan, T., & Buzan, B. (1997). The mindmap book.
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6.15
Group Therapy: A Cognitive-
behavioral Interactive Approach
SHELDON D. ROSE
University of Wisconsin±Madison, WI, USA

6.15.2 THE IMPLICATION OF THE GROUP IN CBIGT 321
6.15.3 THERAPIST ACTIVITIES IN CBIGT 324
6.15.3.1 Pregroup Planning 324
6.15.3.2 Orientation to Group Therapy 325
6.15.3.3 Assessment 325
6.15.3.4 Intervention 328
6.15.3.5 Generalization 328
6.15.4 INTERVENTION STRATEGIES USED IN CBIGT 329
6.15.4.1 Systematic Problem-solving 329
6.15.4.2 The Modeling Sequence 329
6.15.4.3 Cognitive Change Methods 331
6.15.4.3.1 Cognitive restructuring 331
6.15.4.3.2 Self-instructional training 331
6.15.4.4 Relaxation Methods 332
6.15.4.5 Reinforcement and Stimulus Control 332
6.15.4.6 Small-group Procedures 333
6.15.4.6.1 Role-playing 333
6.15.4.6.2 Subgrouping 333
6.15.4.6.3 Buddy system 333
6.15.4.6.4 Group exercises 333
6.15.4.6.5 Group feedback 334
6.15.4.7 Identifying and Resolving Group Problems 334
6.15.4.8 Phases of Group Development 335
6.15.4.9 Integrating Diverse Intervention Strategies in CBIGT 335
6.15.5 SUMMARY AND CONCLUSION 336
6.15.1 INTRODUCTION are many types of group therapy, one of which

makes use primarily, though not exclusively, of
Group therapy is widely used as the context cognitive and behavioral procedures. The
of treatment for patients with a variety of purpose of this chapter is to describe the
problems and concerns. In a recent survey of rationale for, review research concerning, and
mental health providers in a middle-sized present one general approach and the techni-
American city, it was noted that 72% of the ques commonly applied in this form of group
providers made the option of group therapy therapy primarily for adults. Unfortunately, in
available to their patients (Rose, 1998a). There the existing literature, the role of the group is
319
320 Group Therapy: A Cognitive-behavioral Interactive Approach
rarely explicated (see Rose, Tolman, & Tallant, effectiveness than control groups in the treat-
1985, for a review of the cognitive-behavioral ment of a variety of presenting problems. For
group therapy literature until 1984). example, Spence (1991) demonstrated that
Because of this neglect the potential use of the CBGT was equivalent to individual cognitive-
group as a set of interventions in itself in behavioral therapy and both were more effec-
administrating cognitive and behavioral proce- tive than a wait-list control in the treatment of
dures is described in this chapter. Because the chronic occupational pain. Oneytt and Turpin
approach lends itself to evaluation and specific (1988) found that a six-week cognitive-
description of its primary intervention, assess- behavioral group treatment was more effective
ment, and generalization strategies, cognitive- than a control group but equivalent to
behavioral group therapy appears to be growing individual general practitioner appointments
in popularity among practitioners and patients. in the reduction of benzodiazepine use and
Its relevance in particular for women has been anxiety. All changes were maintained at 15-
described by Wolfe (1987) and for minorities in week follow-up. The results are confounded
studies by La Framboise and Rowe (1983) and somewhat by the fact that the general practi-
Comas-Diaz and Duncan (1985). tioner may not have used cognitive-behavioral
Cognitive-behavioral group therapy (CBGT) methods. Teri and Lewinsohn (1986) also found
refers to an approach that occurs in groups and that both individual and group behavioral
makes use of behavioral (e.g., modeling and treatment were equivalent and both were more
reinforcement), cognitive (e.g., cognitive restruc- effective than a wait-list control in the treatment
turing, self-instructional training, problem- of patients with moderate depression.
solving), relational change methods, and group Support for the effectiveness of CBGT has
procedures to enhance the coping skills of the also been demonstrated in studies in which
participants and to resolve or ameliorate rela- CBGT was compared to wait-listed and other
tional problems they may be experiencing. approaches. When Wolf and Cowther (1992)
Coping skills refer to that set of behaviors and compared CBGT with behavioral treatment for
cognitions which facilitate adaptation to stress- 41 bulimic women, both were more effective
ful or problematic day-to-day situations. Some than an extreme weight control method in terms
coping skills which participants learn in CBGT of reduced bulimic tendencies. CBGT was also
are systematic problem-solving, relaxation, more effective than the behavioral treatment
meditation, imagery, techniques for ªdecatas- measures in the treatment reduction of severity
trophizing events,º correcting other cognitive of psychopathological symptoms and preoccu-
distortions, being appropriately assertive, dis- pation with dieting. Lee and Rush (1986) had
tancing or objectifying one's pain or strong similar results with 30 bulimic patients. Those
emotions, communication skills in dealing with receiving five weeks of CBGT reduced their
others, negotiation, and making more effective binging and purging behavior significantly more
use of social networks and increasing social- than those in a wait-list control group. However,
recreational skills. Many of these skills are both only four of the CBGT patients showed a full
target behaviors and a means of intervention for remission of the binging and purging behavior.
learning more specific target behaviors. When Bottomley, Hunton, Roberts, and
Group treatment approaches in general when Jones (1996) compared nine patients in CBGT
compared with individual approaches seem to to a eight patients in social support group and to
fare favorably. A meta-analysis (Toseland & 14 ªdeclinersº for newly diagnosed and psy-
Siporin, 1986) reviewing all group vs. individual chologically stressed cancer patients, they found
therapy comparisons (many of which were that the CBGT patients significantly improved
cognitive and behavioral) showed evidence that their coping styles in comparison with the other
groups are at least as effective and sometimes two conditions. At three-months follow-up, the
more effective than individual treatment and differences washed out possibly because two
more efficient in that more patients can be dealt CBGT patients had died.
with effectively for the same cost. This finding Ehlers, Stangier, and Gieler (1995) compared
was confirmed by Tilliski (1990) who used only cognitive and behavioral methods carried out in
those studies from the Toseland and Siporin groups with intensive or standard dermatolo-
review that contrasted group, individual, and a gical treatment. They found that the behavioral
control group. In all cases, regardless of theory treatments for atopical dermatitis resulted in
or problem focus, there was no difference significant improvement in skin condition and
between treatments and significant differences in topical steroids used when compared to
between treatment and the control group. Since dermatological condition alone, at one-year
that time several studies involving CBGT have follow-up. Once again, the group factor and the
appeared which also support the equivalency of behavioral methods were confounded in the
individual and group therapy and their greater experimental condition.
The Implication of the Group in CBIGT 321
Fals-Stewart, Marks, and Schafer (1993) Although each of the above researchers treat
compared a behavioral group therapy condition the given problem area in groups using
(n=30) consisting of group exposure and cognitive-behavioral and/or behavioral inter-
response prevention with an individual therapy vention strategies, most use different combina-
condition (n=31) using the same methods and a tions of these techniques and, as already
relaxation control condition (n=32). The sub- mentioned, a few describe specific uses of
jects were randomly assigned to the conditions. groups in the treatment process such as member
Patients in all three conditions showed stress modeling and building cohesion of the group. In
reduction at the end of treatment, but only in the summary, modest support for CBGT can be
behavioral conditions were the gains signifi- identified. Usually in the control group and
cantly maintained at the six-month follow-up. databased case studies, the group factor and the
Lutgendorf, Antoni, Ironson, and Klimas cognitive-behavioral techniques are con-
(1997) tested the effects of a 10-week cognitive- founded, thus making interpretation of the
behavioral group stress management program findings unclear as to whether group or the
on mood and immunologic parameters in HIV- cognitive-behavioral strategies are the major
seropositive gay men whose disease had pro- causes of change.
gressed to a symptomatic stage. The patients Because of the variations mentioned above,
were randomly assigned to the CBGT (n=14) different kinds of cognitive-behavioral ap-
or a wait-list control group (n=12). At the end proaches to CBGT exist. Some primarily rely
of the 10 weeks patients in the CBGT condition on cognitive, relaxation, relational, and didactic
significantly decreased self-rated dysphoria, procedures, while others integrate with the
anxiety, and total distress. The intervention cognitive procedures extensive behavioral
also decreased Herpes simplex virus-type 2 methods such as modeling and reinforcement
(Hsv-2) immunoglobulin G antibody titers. No into the treatment program. Only a few make
such changes were found in the control group. specific uses of the group. Because of our
There was no follow-up measurement. clinical and research experience with a model of
Subramanian (1991) found that 39 chronic CBGT that incorporates group techniques into
pain patients in eight weekly sessions of CBGT treatment, the purpose of this chapter is to
improved significantly more than a wait-list present a cognitive-behavioral model that
control (n = 20) in the areas of physical and indeed makes use of the group. In this chapter
psychosocial dysfunction, but showed no the specific model that includes the extensive use
difference in the experiencing of pain. Group of group methods and a focus on group
strategies as well as cognitive-behavioral stra- variables that impinge on outcome along with
tegies were described in this study. However, in the use of cognitive-behavioral procedures is
a follow-up study, Subramanian (1994) found referred to as cognitive-behavioral interactive
that the gains of a subsample that could be group therapy (CBIGT), while CBGT refers to
located were not maintained. However, no all group models using cognitive-behavioral
specific steps in and after the therapy program methods, whether explicit use of the group has
had been taken to achieve maintenance. been determined or not.
Patients in CBGT in a number of before and
after multiple cases without control groups have 6.15.2 THE IMPLICATION OF THE
consistently shown significant change over time GROUP IN CBIGT
and for the most part these changes were
maintained 2±3 months following treatment. Originally the group was used in therapy
These studies include coping with generalized because of its convenience and efficiency in
anxiety (Lindsay, Gamsu, McLaughlin, Hood, treating more than one or two people at the
& Espie, 1987; Power, Simpson, Swanson, & same time. As many scholars of group therapy
Wallace, 1990), adaptation problems of recently have noted, it has a number of other advantages
divorced women (Graff, Whitehead, & Le- (e.g., Yalom, 1985, p. 3). Improved opportu-
Compte, 1986), managing one's depression nities for assessment is a major contribution of
(Abraham, Neundorfer, & Currie, 1992), social therapy in groups. The group therapist has the
phobia (Enright, 1991), obsessive-compulsive opportunity to observe live interactions as
disorders (Krone, Himle, & Nesse, 1991; Van opposed solely to second-hand accounts of
Hoppen, Rassmussen, & Eisen, 1991), insomnia interactions and make solid conclusions as to
(Kupych-Woloshyn, MacFarlane, & Shapiro, social skill strengths and deficiencies. He or she
1993), and a heterogeneous population of 531 can hear the cognitive distortions typical of
patients suffering from various psychiatric many patients being played out in the group.
problems in intensive CBGT at a private This is possible only insofar as there is broad
psychiatric clinic (Manning, Hooke, Tannen- participation among the patients which is the
baum, & Blythe,1994). focus of many interventions in CBIGT.
The group provides the patient with a source reinforce the completion of extragroup task
of feedback about those behaviors which are completion if the members report publicly at the
irritating or acceptable to others and about beginning of the following session what they did
those cognitions which can be viewed as for their task during the week.
distorted or dysfunctional. In CBIGT, partici- Negotiating rather than assigning homework
pants are trained to help each other be concrete tasks in CBIGT and the use of extensive
in the formulation of problem situations and the feedback from members and brainstorming
cognitive, emotional, and behavioral responses increases the power of the members and reduces
of the patient to those situations and to identify the excessive didactic quality of many other
specific goals towards which intervention is models of CBGT. Specific questions on weekly
aimed. postsession questionnaires (see Table 1) keeps
Another advantage of using the group in the therapist in touch with the group's evalua-
CBIGT is the frequent and varied opportunity tion of their own participation and power in the
for mutual reinforcement which for patients is group.
often far more powerful than reinforcement by Finally, Yalom (1985, p. 14) points out the
the therapist only. Each patient is given the importance of helping others (altruism) in
chance to learn or to improve his or her ability facilitating therapy in groups. Although he
to mediate rewards for others in social inter- refers to insight-oriented group therapy, the
active situations (with acquaintances, friends, same appears to be true for CBIGT provided
family members, acquaintances in other groups, that the therapist creates conditions which
fellow therapists, or employer). The group permit patients to help each other. In this
therapist in CBIGT creates situations in which way the participant is not only a patient, he or
each patient has frequent opportunities, in- she is also a co-therapist±teacher within the
structions, and rewards for reinforcing others in given structure. This appears to increase the
the group. In CBIGT, special exercises have participant's sense of self-efficacy or the belief
been designed to train patients specifically in that he or she can perform in such a way as to
mutual reinforcement, and often extragroup achieve a desired outcome (Bandura, 1977).
tasks (homework) are used to encourage them Yalom (1985, p. 8) also reminds the reader of the
to practice reinforcement skills in the real world. principle of universality. Patients experience
High levels of reinforcement, among other that they are not the only person with the given
techniques, contribute to the cohesion of the problem, as serious as it may be.
group. As Yalom (1985, p. 49) argues, group Of course, groups are not without disadvan-
cohesion is the equivalent in groups to relation- tages. The time allotted to each individual is
ships in individual treatment. At least in the drastically reduced in most groups compared to
early phase of therapy, cohesion must be high if individual treatment. Thus, individualization of
other methods are to be maximally effective. patients may suffer. If the group process is
If cohesion is high, the group creates the utilized in treatment, the amount of material
opportunity for the group therapist to mobilize covered is less than when the group process is
the members to use of a wide variety of coping ignored. In addition, it is difficult to assure the
skill training procedures that are either unavail- patients of the confidentiality of their comments,
able or less efficient in the therapeutic dyad. For even though the therapist emphatically points
example, the most effective way of systematic out its importance. For this reason, some
problem-solving is in the group. In the ªbrain- individuals in group therapy are less likely to
stormingº phase of problem-solving, the multi- self-disclose relevant material than they would in
plicity of patients and patients' experiences individual therapy. However, many others are
results in numerous ideas and suggestions. The encouraged by the modeling of other members to
group also provides a large number of models, self-disclose more readily. Usually as the group
role-players for behavioral rehearsal, manpower progresses, interpersonal trust increases, and the
for monitoring, and partners for use in a ªbuddy patients become more comfortable with self-
system.º disclosing significant concerns. Another danger
In CBIGT, as well as most other CBGT of CBGT is its tendency to become excessively
models, members are expected to carry out didactic because of the amount of material to be
homework or extragroup tasks which are disseminated. This didactic quality may reduce
cognitive, behavioral, or both, to practice what the cohesion of the group and reduce the benefits
they have learned in the group. Much of the which might otherwise ensue. Also, the oppor-
program in CBIGT is designed to prepare the tunity for altruistic activities is diminished. For
members for completing those tasks. If appro- this reason, in CBIGT group therapists are
priate norms are established, the group serves to encouraged as early as possible to create
enhance the design through group feedback and conditions that maximize patient participation
mutual supervision in subgroups, and to and self-determination. The use of small group
The Implication of the Group in CBIGT 323
Table 1 Example of a postsession questionnaire.
code name±±±±group name±±±±date±±±±

1. How useful was this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
not at all very little somewhat quite a bit extremely
2. How actively involved were the members in today's session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
3. How helpful were members to each other during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
4. How much did the members reveal about themselves (their real thoughts, feelings,
motivations, and or concerns) during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
5. How bored or tired looking were the members during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
6. How close did the members feel to each other during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
7. How upset or angry were the members during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
8. How task oriented were the members during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
9. How important were the problems the group worked on in this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
10. How much did the members control the content and direction of this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
11. How much conflict was there during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
12. To what degree were the goals of the session acheived?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
13. How anxious were you during this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
14. How prepared were you for this session?
1±±±±2±±±±3±±±±4±±±±5±±±±6±±±±7±±±±8±±±±9
15. What specifically did you find useful in todays session?
16. What specifically did you find unhelpful in todays session?
exercises especially in subgroups (see Rose, 1997, literature the groups are predominantly White
for a description of most of these) also enhances middle class. Some groups are homogeneous in
broad participation. terms of gender and race. Some single case
research and descriptions of clinical experience
point to the efficacy of CBGT (although not
6.15.3 THERAPIST ACTIVITIES IN CBIGT necessarily CBIGT) approach with Hispanics
(see Comas-Diaz & Duncan, 1985), Native
One cannot merely assume that if a problem
Americans (La Framboise & Rowe, 1983;
and the appropriate coping skills are identified,
Schinke & Singer, 1994), and economically
one can then intervene at any time in the
disadvantaged depressed women (Azocar, Mir-
therapeutic process with the best techniques
anda, & Dwyer, 1991). Wolfe (1987) makes use
available and help the patient to solve it. In
of all-women groups because consciousness
CBIGT just as in other group therapies, one can
raising is a component of the CBGT model she
identify a number of sets of activities each of
employs. Wolfe (1987) asserts that CBGT and
which is linked to unique and overlapping
in particular, rational emotive therapy in
therapist functions. They are somewhat over-
groups, seem to come the closest to meeting
lapping in time and in content. Differentiating
the criteria for feminist therapy. Sometimes all-
these sets is useful insofaras each set of activities
women groups exist by default rather than by
provides a guide for the group therapist as to
plan as in the case of many parents groups or
when emphasis should be shifted. These include
groups of depressed persons where only women
a pregroup planning, an orientation, an assess-
sign up. All-men groups in CBGT can be found
ment, an intervention, a generalization and
for male abusers, anger management groups in
termination, and a postgroup set of activities.
prisons, and men who are HIV positive.
At least two kinds of basic organization for
6.15.3.1 Pregroup Planning therapy groups can be identified. The first is
open-ended groups in which new group parti-
In planning for therapy, the CBIGT therapist cipants come at any time in the history of the
must establish the group's purposes, assess group and leave at any time. These are usually
potential membership, recruit members, decide found in institutions although some community
on the group social environment or structure, groups are organized in this way as well. It is a
and create the group's physical environment. In more common model with support groups than
determining the group's purposes, the group CBGT groups. The model duration of most
therapist can draw on several sources. Based on open-ended groups is approximately a year,
experience with patients in the agency or although some groups may go on for much
community, the agency may have identified a longer. However, participants may stay for any
need for a certain type of program. Patients may length of time, and they often come and go
have been requesting help for certain types of sporadically. The session length varies from one
problems for which help is not generally or to two hours.
readily available. To the degree that these needs The second type of organization is closed
can be translated into behavioral or cognitive groups which have a fixed beginning and fixed
responses to identifiable problematic situations, end-date for all participants. Most of the
the CBIGT approach can be considered. available research is on this type of group
Decisions must be made as to the theme of and most cognitive-behavioral community
the group, group size, number of therapists, groups are closed. Although there are many
frequency and length of sessions, a sufficient exceptions, most closed groups last from 6±16
number of candidates for the group, and group sessions once a week for one and a half to two
composition. hours. The modal number is eight. Experience
In citing the literature above, it appears that indicates that 12±16 sessions are required to
most cognitive-behavioral groups have a theme, achieve complex or multiple goals. There is
that is, all patients in the group have similar usually only one group therapist except in
problems. A few practitioner±researchers (e.g., training situations. The size of the groups varies
Flowers & Schwartz, 1985; Manning et al., from as few as four to as many as 20
1994) also use CBIGT to deal with more participants. However, with adults the modal
heterogeneous groups (i.e., groups consisting number is eight, which permits participation by
of persons with diverse presenting problems) everyone at any given session and provides a
with positive results. Many of the homogeneous wide variety of ideas and experiences. Most
groups, although comprising members who CBGT groups are sponsored by social agencies,
have similar presenting problems, are diverse clinics providing mental health services, schools
in terms of race, gender, and ethnic background, and colleges, social welfare agencies, and
although in most of the reports from the private practitioners.
Therapist Activities in CBIGT 325
6.15.3.2 Orientation to Group Therapy to review the advantages of the problem state as
well as the disadvantages and to weigh the
As part of recruitment and later during the relative merits of changing or not changing. The
first group sessions, members are oriented to the patients are taught to identify motivational
purposes of the group, the methods to be used, statements made by one another and to
the potential goals that can be achieved, and the reinforce each other as they occur. Throughout
importance of keeping what goes on in the the process the therapist makes ample use of
group confidential. An overview of the group empathic statements which are often emulated
activities and expectations are presented and by the members with each other. The level of
discussed. As part of orientation, group con- motivation is an ever changing process and
tracts are often developed; these contracts requires constant attention by both therapist
establish what the patients can expect from and group members.
the group therapist and the agency and what the
members can be expected to do. These contracts
are often in writing. Patients are also oriented to 6.15.3.3 Assessment
the basic assumptions underlying each of the
treatment techniques used. In this way not only Assessment is a concept central to all
do patients know what is happening to them, empirical approaches. The purpose of assess-
expectations of positive outcomes can be ment is to determine the specific targets of
stimulated. interventions and the specific coping skills to be
In orientation, the therapist in CBIGT also learned, in such a way as to make them
introduces the patients to the use of the group as amenable to intervention, the situations in
a vehicle of treatment. The use of subgroup which these coping skills and other target
exercises (Rose, 1997) are also initiated. The behaviors should be applied, the social and
therapist draws on patient experience to orient material resources of each patient that might
members to the assumptions of the approach. impinge on treatment, and the potential barriers
Broad group discussion is encouraged by means to effective treatment. It has the additional
of assigned tasks in subgroups and/or in purpose of determining whether the given group
exercises, which is the first step taken to or another type of therapy might be the most
enhance group cohesion. appropriate setting for each potential patient.
Other means of building group cohesion are Finally, it forms the basis for establishing
by using introductory exercises in which treatment goals.
members interview each other, keeping the tone The goals of CBIGT may be changes in the
and interaction of the group positive, encoura- level of intensity of specific behaviors or an
ging others to provide frequent mutual re- increase of more general adaptive coping
inforcement, noting similarities as well as behaviors. Among those specific target beha-
differences among members in terms of back- viors that patients have worked on in CBIGT
ground and presenting concerns, keeping the and on which research exists have been
group small, providing occasions for the mentioned earlier. These include reducing the
patients to help each other, permitting and extent or intensity of agoraphobia, social
encouraging physical movement during the phobia, mood swings, obsessive-compulsive
session, using humor, using role-playing, pro- behaviors, smoking, alcohol and drug abuse,
viding variation in program and program binging and purging, stress reduction, anger
media, and providing or having the members responses, and pain responses. Positive targets
provide refreshments (see Rose, 1989, involve sleeping regularly, specific ways of
pp. 250±251, for additional detail.). making and keeping friends, increasing social
One can also develop cohesion by enhancing activities, making more effective use of the
the motivation of the members. Groups can patient's social network, improving relation-
serve to develop motivation primarily if the ships and communication skills. Another set of
group therapist takes specific actions (see Miller target phenomena are the development of
& Rollnick, 1991, for a discussion of these coping skills which mediate resolution of the
principles in more detail as they apply to the target behavior. Two kinds of coping skills can
individual therapy of people who abuse drugs be identified, cognitive and behavioral.
and alcohol). In the first place the therapist Cognitions refer to thoughts, images, think-
should accept and encourage the patients to ing patterns, self-statements, expectations, or
treat ambivalence or reluctance to participate as other private or covert events which may be
normal phenomena. No pressure is placed on inferred from verbal or other overt behavior.
the participants initially to change or to get out Cognitive coping skills are those cognitions
of ªdenialº either by the therapist or the other which facilitate coping with internal and social
group members. The members are encouraged phenomena. Examples are skill in analyzing
one's own cognitions, in labeling appropriately blems of self-control, which are targets of
one's self-defeating self-statements, in obser- change or the themes of many groups in CBGT.
ving and rehearsing new, more appropriate self- As part of assessment the therapist ascertains
statements, and in reinforcing oneself covertly. the degree to which these self-management skills
Though important skills in their own right, are present and the target behaviors in which the
some cognitive coping skills also mediate the self-management skills can be directed primarily
attainment of the more observable social skills by means of patient self-report and situational
and other behaviors mentioned above or other analysis. These self-management skills, if
coping behaviors. Thus, the goal of increasing learned, represent a set of strategies that the
cognitive coping skills is important as a means patient can utilize even when only limited
of reducing the frequency of anxiety-inducing external support is available.
and behavior-inhibiting cognitions, in dimin- Among the most common behavioral coping
ishing the intensity of anxiety, and in improving skills are social skills, a set of learned perfor-
social behavior (Beck & Emery, 1985; Mei- mance behaviors that relate an individual to
chenbaum, 1977). Self-statements, such as others. These include such behaviors as respond-
ªeveryone thinks I'm strange,º not only may ing to criticism, techniques of dealing with other
produce anxiety, but promote inaction or self- people (family, friends, colleagues, strangers) in
defeating action. Changing such self-statements stressful situations, asking for help when needed,
to something like ªSure, I'm different than disagreeing constructively. They may even be
others in many ways, some things I like and more specific such as giving appropriate eye
some I'll changeº may reflect a more accurate contact in conversations or smiling occasionally.
appraisal, may suggest avenues of change, is These social behaviors are often essential for
more self-respecting, may reduce anxiety, and effective social fuctioning and can be readily
ultimately should improve social behavior. In taught in the group. Social skill inventories (e.g.,
order to teach these coping skills, assessment Gambrill & Richey, 1973) and role-play tests
involves having the patients examine each (Magen & Rose, 1998) are commonly used to
others cognitions in the situational analysis of assess patient skills in this area.
stressful or anger-inducing situations. Check- Recreational and leisure time skills may also
lists (e.g., see Piacentini, 1993, for a description be regarded as behavioral coping skills. The
of most of these) are also used: keeping track of extent of these interests are explored in
one's cognitions with such procedures as Beck's assessment to determine whether they should
(1976) three-column technique in which the be amplified or modified. Although some are
patient records in the first column an anxiety- or social in nature, they may be regarded as a
anger-producing situation; in the second, his or separate category for coping with general life
her automatic thoughts or thinking errors; and stress. Information about these skills and
in the third, types of errors found in these interests are obtained in a group exercise in
thoughts. These are then shared with other which the members interview each other in pairs
members of the group. about their interests and leisure time activities
Another set of cognitive coping skills is the and then each reports his or her partner's
problem-solving sequence described earlier interests and skills to the group.
(D'Zurilla, 1986). In assessment, the therapist Because therapy does not go on forever,
determines the patterns of problem-solving of patients will have to learn to make use of their
each of the patients by means of the social social network more adequately. A number of
problem-solving inventory (D'Zurilla & Nezu, social network surveys have been developed
1988). Simulated problems can also be pre- which the patients fill in and ascertain the
sented to the group for the members' solutions. relative helpfulness and limitations of the
The therapist can observe the process. Those various social units of which they are a part
who are either impulsive or chaotic problem- (see e.g., Rose, 1998b, p. 329, for an example).
solvers would profit from being able to In the group they share the results of the survey
approach problem situations in a careful, with other members.
step-by-step, analytic, and planful way. Numerous other noninteractive coping skills
Self-management refers to those cognitive can be explored as part of assessment such as the
coping skills by which patients control their patients's ability to manage his or her time, or to
own environment as a means of controlling relax or mediate during stressful situations.
their own behavior. Procedures such as the use Skills in relaxation can be readily observed as
of environmental cues, self-monitoring, self- they are taught and tried out in the group.
instruction, self-modeling, self-evaluation, and Relaxation is frequently used as part of most
self-reinforcement fall under this rubric. These cognitive-behavioral programs. In most cases,
are used in changing patterns of smoking, drug coping skills and specific behavioral targets are
and alcohol abuse, studying, and other pro- intertwined.
Therapist Activities in CBIGT 327
One cannot learn coping skills in a vacuum. problem area encounter. The group therapist
One must identify the specific situations with develops a set of predetermined or ªcannedº
which the individual must learn to cope. To this situations for those members who cannot
end the group members are taught to identify develop one for themselves. An exercise is used
and define their unique problematic situations. to train the members in defining relevant and
The therapist first provides models of such useful situations. In this exercise a number of
situations, which the members discuss in terms models of situations are presented and the
of the criteria for formulating troublesome members analyze whether the criteria for ªuse-
situations they have thus far had trouble dealing fulº situations are met.
with. For example, in a group of men working As part of assessment and to determine the
on reducing the frequency of drinking behavior, progress of treatment, data on patient behavior
an example of a situation in which a coping and the resolution of problems are usually
response was required was as follows: systematically collected before, throughout, and
following therapy, and several weeks or months
A friend of yours stops you after work. He urges after therapy. In order to understand patients'
you to have drink with him. He notes that several reponse session by session to the program as a
other old friends will be there. You have refused whole, a postsession questionnaire is filled out
and then he says, ªwhat kind of friend are you, if by all the patients and the therapist at the end of
you can't have a drink with your old buddies.º each session (see Table 1). In summary, some of
the methods of collecting data mentioned above
A group of patients who have problems mana- include diaries, personality inventories and
ging their stress are presented with the following checklists, role-play tests, sociometric tests,
example of a situation that might increase stress self-observation, direct observations of the
and which they will analyze as a group: group or of individuals when not in the group,
postsession questionnaires, and interviews.
Your car has just been ticketed. You are only eight (Each of these are discussed in more detail in
minutes late for your meter. You really rushed to Rose, 1989, pp. 109±136 for adults, and Rose,
be back on time. You tell yourself it isn't fair. You
1998, pp. 130±151 for adolescents.) The more
know people who are hours late and don't get
parking tickets. You feel the tension rising in your structured methods permit evaluation of out-
stomach. come, one of the purposes of assessment.
Based on the initial data collected in the first
An example used for a group of men who batter part of assessment, goals are eventually estab-
is the following: lished together with the patient. These goals are
usually in terms of the specific target behaviors
You get home right on time. You've had a couple
and cognitions that the patients need to achieve
of drinks, nothing much, you feel, and your wife by the end of treatment and the coping
says she smells alcohol on your breath, you feel behaviors required to deal with the problem
anger rising, your head hurts, you say to yourself situations. Knowing each other well because of
she can't talk to me that way. If she loves you, you their intense interaction, the group members
think, she won't nag me. It's my life, I'll drink what provide each other with ideas as to goals each
I want. might pursue and feedback as to the formula-
tion of the goals, the importance of the goals,
The criteria for a situation that readily lends and the degree to which these goals are realistic.
itself to examination are that the situation is Goals may be either behavioral, affective, and/
important to the patient and likely to occur or cognitive change.
again, that it is specific as to time and place and Some examples of common treatment goals
the people involved, and that it represents a that people have worked towards in these
situation the patient might have difficulty in groups are:
dealing with. After discussion of the application
of these principles to the model situations, as an 1. (For the depressed patient) By the end of
extragroup task it is suggested that each person treatment, I will participate in at least two social
develop one or more such situations which activities every week with friends or family mem-
would be presented at the following session in bers. I will also identify any self-defeating thoughts
the group in terms of how well each situation I make and will change each into a coping thought.
On my self-monitoring card, I will score an average
meets the criteria. After working with a group of 5 or lower on the 10 point depression scale.
for a while, the therapist can put together a role- 2. (For the angry and abusive male) By the end of
play test consisting of a wide variety of such treatment when I begin to feel angry, I will take a
situations (see e.g., Magen & Rose, 1998) to deep breath and let it out slowly and remind myself
ascertain the social skills needed to deal with that I can destroy my marriage if I give way to it.
social situations the patients with a common When I experience the first signs of anger with my
wife, I will excuse myself from the situation and 6.15.3.5 Generalization
walk away. I will also increase the number of
compliments I make to my wife to a minimum of Generalization, a concern of all therapies,
once a day. refers to the process of transferring what the
patient has learned in the group to the outside
The criteria for effective goal formulation are world and maintaining what he or she has
that the goal is important to the individual, that learned beyond the end of therapy. The most
a time frame be provided (e.g., by the end of fundamental principle of generalization is that it
treatment or by next month), that the goal be rarely occurs without taking steps to see that it
sufficiently specific that the patient knows when occurs (Stokes & Baer, 1977). One of the major
he or she has achieved it, and that the goal is strategies in CBIGT for transferring learning
realistic. If necessary, subgoals may also be from the group to other situations involves the
formulated which are even more concrete. use of extragroup tasks, described above, which
The patients are trained in goal formulation are used in almost every session.
by means of an exercise in which the model goals The patients are prepared by modeling and
such as those above are provided, the above rehearsal on how to deal with persons un-
criteria for effective goals listed, simulated goals sympathetic to their changes. Former patients
are presented and these are corrected in group are sometimes brought in to discuss the
discussion. Then the members formulate their possibilities of setbacks and how they might
own goals which are evaluated by the group in be handled. Possible self-referral sources are
terms of how well the goals meet the above discussed, such as a counselor or a local clinic or
criteria. Once goals are formulated, an addi- health service. Finally, as part of this phase, a
tional means of measurement, goal attainment follow-up or ªboosterº session would be held
scaling, can be used to ascertain progress two or three months following therapy.
towards goals (see Cardillo, 1994). The goal The members are taught the general princi-
attainment scales are developed in the group ples of what they practice specifically. For
with the members helping each other. Following example, they learn the general steps for
the formulation of goals, group programs and problem-solving. They learn the principles of
interventions can be planned which facilitate the how anxiety and stress is in part a function of
achievement of these goals. how we evaluate situations. They learn the
principle that if one practices a given behavior it
is more likely that they can learn that behavior.
6.15.3.4 Intervention In CBIGT one goes from the specific exercise
and experience to learning the general principles
Based on the goals, intervention activities behind them.
change or maintenance or decisionmaking Members are finally prepared for termination
strategies are selected. The patients are oriented by getting them to develop a plan for how they
to these procedures, and with their concurrence, intend to apply what they have learned in the
the strategies are applied. Specific strategies are group when the group ends, and by designing
selected which have empirical support as well as activities appropriate to practicing their newly
a relationship to the goals. learned skills. These plans often contain such
In order to develop these and specific actions as joining a nontherapeutic group,
behavioral and coping skills, usually no one reading a self-help book, practicing relaxation
intervention technique is sufficient. A number on a regular basis, meeting with a group member
of methods of teaching patients necessary to talk about the principles learned in the group,
specific skills include problem-solving, model- and meeting again for a booster session.
ing (overt and covert), rehearsal, coaching, In order to diminish the intensity of the
cognitive-restructuring, rational-emotive tech- relationships of the members with each other
niques, self-instructional training, reinforce- and with the group therapist as the group
ment and stimulus control, sociorecreational, approaches termination, the therapist en-
relaxation training, and small-group techni- courages members to establish relationships
ques. In CBIGT most of these methods with outside of the group and to become involved in
special emphasis on the group are combined extragroup activities such as family activities,
into one integrated approach. A method is bowling leagues, bridge clubs, dancing lessons,
selected for inclusion preferably if it has some and social organizations. Furthermore, rela-
independent empirical foundation and some tionships with nongroup members are encour-
relationship to the above mentioned targets. In aged. These new activities and social
the following sections, most of these methods relationship become the focus of the later
will be reviewed in terms of their contribution to sessions in CBIGT. Extragroup tasks become
the total approach. less structured but more extensive. Preparation
Intervention Strategies used in CBIGT 329
is largely in the hands of the patient. Monitoring procedures are used to prepare the group
is less strict. Social, recreational, and other members to impliment the solutions they have
cohesion-building activities are kept to a agreed to. Each of these have their own empirical
minimum in the group. Many of the leadership foundation. One of the most important is the
functions are performed by group members (see modeling sequence.
Table 2).
6.15.4.2 The Modeling Sequence
6.15.4 INTERVENTION STRATEGIES This sequence is designed to teach specific
USED IN CBIGT interactive behaviors for coping with various
The most commn intervention strategies used problems situations, and includes such techni-
in CBIGT are systematic problem-solving, the ques as overt modeling, behavior rehearsal,
modeling sequence, cognitive change proce- coaching, and group feedback. Modeling refers
dures, relaxation, reinforcement and stimulus to learning that occurs through the observation
control, and small group procedures. of a model who might be the group therapist,
another member of the group, someone in the
6.15.4.1 Systematic Problem-solving patient's environment, or an admired person on
stage, on screen, in novels, or in public life.
Systematic problem-solving is a central meth- Modeling may be role-played in the group or it
od to CBIGT insofaras patients bring proble- may be observed directly in real life. Modeling is
matic situations of concern to the group and the specifically used to demonstrate how a situation
group under the guidance of the therapist problematic to one or more patients in the
attempts to help them find solutions to those group may be handled effectively. Behavioral
problems. It is systematic insofaras the members rehearsal is a role-play technique in which a
follow (or deviate by plan from) specified steps. patient with a given problem situation practices
The steps characteristic of the problem-solving new, more effective ways of handling that
process include orienting the members to the situation. Coaching refers to instructions,
basic assumptions of problem-solving, defining verbal or physical cues given to the patient
the problem, generating alternative solutions, when she or he is modeling or rehearsing a set of
selecting the best set of solutions, planning and behaviors in a given situation.
preparing for implementation, implementing the Group feedback is the verbal evaluation from
solution, and evaluating the outcome (except for others as to how effectively the patient role-
ªpreparation for implementationº which has played or modeled. Following the modeling
been added, these steps are taken from D'Zur- sequence, the patient prepares for and carries
illa, 1986). Many of the steps of problem-solving out extragroup tasks to practice the newly
can be classified other than as intervention. For learned coping skill in the real world.
example, orientation to problem-solving is an
orientation activity, defining the problem is Following the situational analysis of the situation
clearly a part of assessment, implementation calling for a refusal of drink when offered (see
through extragroup tasks is part of the general- example above), the therapist asks the group
ization of change, and the other steps are members for possible responses to the one of
intervention activities. agreeing with the friend and going with him which
Problem-solving is not only a general para- is what the patient, Pete, had done in the original
digm. It can be identified as a set of coping skills event. Based on the suggestions of his fellow
patients, Pete decided that he would like to refuse
to be learned in their own right to replace clearly and in a matter-of-fact tone of voice,
impetuous or uninformed problem-solving. In reminding his friend that he (Pete) was on the
using the problem-solving method to find more wagon and was working hard to stay there and he
effective ways of copying with the many would appreciate whatever help his friend could
problems of concern to group members, patients give him. Pete would repeat the statement if
learn the skills involved in carrying out the pressured further. The therapist set the scene
general problem-solving paradigm. Such a set of outside a bar, and then modeled the situation
procedures can be effectively taught in groups with one of the other group members acting as the
since the general paradigm is repeated fre- friend. Then Pete, who felt that one demonstration
quently in the course of therapy not only dealing was enough, played himself and his friend was
played by the same person as in the first role play.
with individual problems but also in dealing with When it was finished the therapist asked the other
group problems should they arise. Moreover, patients to tell Pete what he did well and then what
once learned, it can be used by patients to deal he might consider doing differently. The members
with problems long after the group has ended. responded that Pete made an impressive statement
Within the framework of problem-solving, a and didn't argue. They suggested that he might
number of other cognitive and behavioral consider giving better eye contact and speaking in
Table 2 Group development in a structured group.
Group phase Therapist behavior Group processes
Orientation phase Orients members to theory and approach Factual communication, limited
Ascertains levels of motivation self-disclosure
Encourages broad participation High mutual anxiety
Orients members to each other Feedback is limited and polite
Introduces rules Norms loosely established
Promotes protherapeutic norms Leadership functions primarily
controlled by therapist
Preliminary work Stimulates moderate self-disclosure Weak subgroups begin to form

phase Examines problem situations Increase somewhat in cohesion
Extragroup tasks introduced Members focus attention on therapist
Trains in effective feedback Feedback is descriptive and positive
Teaches basic concepts Distribution of participation broadens
Initiates brief role-plays
Deterioration or Examines nonproductive activities Homework completion rate drops

conflict phase Group processes becomes more flexible Feedback is more negative
and empathic Anger and withdrawal begin to intensify
Begins to look at consequences of present Cohesion begins to weaken
behavior Roles and norms are challenged by some
Initiates discussion of group problems members
Introduces concept of cognitive
distortions
Introduces group problem-solving
Resolution phase Assists members to assume responsibility Feedback to each other more
for therapy constructive
Encourages leadership from members Cohesiveness decreases slightly
Deals with complex situations Group engages in systematic problem-
solving
Distribution of participation increases
broadly
Interaction more task oriented
New protherapeutic norms
Higher levels of cohesion
Secondary work Therapist reduces own activity Members assume major phase
Reduces frequency of reinforcement leadership functions
Encourages members to work on complex Significant self-disclosure to each other
problems Cohesion decreases slightly
Interaction highly task oriented Rate of homework completion high
Rate of homework completion high
Termination Points to principles of generalization Group is more spontaneous

phase Prepares for termination Cohesion diminishes, focuses on
Increases own activity slightly extragroup social units
Summarizes progress Group focuses on future actions
Helps individuals to plan post-therapy
activity
a more matter-of-fact tone of voice. Pete rehearsed cannot handle the situation. He or she instructs
one more time, trying to incorporate the sugges- the observers as to what they should observe.
tions with the ªfriendº in the role play being much He or she makes sure the tempo is reasonable.
more insistent. He or she makes sure that the role-play remains
task oriented. Modeling is an excellent group
The therapist is the director of the role-play. He procedure because of the presence of many
or she coaches significant others and the target potential models and rich source of feedback,
person when necessary. He or she stops the role- and the opportunity for client leadership if these
play before it goes on too long or if the person characteristics are taken advantage of.
6.15.4.3 Cognitive Change Methods identification of each person's distorted think-

ing, the other group members are taught to ªrub
Cognitive change methods refer to the steps inº the errors in each person's thinking through
taken to train the patient in more effective ways logical disputation and analysis. Supportive
of thinking about or evaluating him or herself as evidence is also sought through interviewing by
the patient responds in specific problematic the other group members either to invalidate or
situations. In groups many different cognitive validate the assumptions of each client. In
procedures are used, often in combination with addition, as members relate ongoing problem
each other and with other types of procedures situations to the group, they are asked to note
such as the modeling sequence. It is assumed their thinking in these situations and to identify
that in a given set of circumstances cognitions in and ask the peers to identify any cognitive
part mediate overt behavioral and affective distortions.
responses. These cognitions include how one Once the distorted thinking is identified and
values oneself and one's action and how one labeled, each patient, assisted by the other
specifically thinks in or evaluates a given group members, is asked to replace the distor-
situation. In CBIGT the most commonly used tions with coping statements. Group exercises
cognitive procedures are cognitive restructuring are used to facilitate this replacement in which
(Beck, 1976), which includes rational emotive the patients first correct the list of ªcannedº
techniques (Ellis, 1973), and self-instructional statements of distorted or dysfunctional state-
training (Meichenbaum, 1977). ments. To facilitate this process, a list of coping
statements is presented as points-of-departure.
For example, ªif I take one step at time I can
6.15.4.3.1 Cognitive restructuring
handle this,º or ªI should remind myself to take
Cognitive restructuring is characterized by a deep breath and relax,º or ªif I make a mistake
two sets of procedures. First, one set of it's not so terrible; nobody is perfect.º
procedures is to identify the distorted patterns Once the members become skilled in repla-
of thinking and/or dysfunctional schemata cing cognitive distortions with coping state-
(Beck, 1976) which interfere with social func- ments on simulated examples, they can begin
tioning or create intensive emotions. Second, a with the help of the group to replace distorted
set of methods are used to replace such distorted thoughts of their own with coping statements. If
or dysfunctional thinking with self-statements they have difficulty the group can provide each
that facilitate effective coping with day-to-day other with corrective information or they can
life events and reduce anxiety and stress. In the ªbrainstormº alternate ways of thinking about
first set of procedures the patients are trained to a given situation which might help them to cope
identify cognitive distortions in case examples with the situation.
or group exercises and to label them into such Finally, the members assign each other tasks
categories as absolutizing, catastrophizing, to perform outside of the group to try out and
mind reading, selective perception, or prophe- self-monitor their use of coping self-statements
sizing (Beck, 1976). In one exercise the group to replace cognitive distortions. At a subsequent
members are given a list of self-statements session each patient reports back his or her
which represent both cognitive distortions and observations to the group.
coping statements. They are asked to identify
independently to which category each statement
6.15.4.3.2 Self-instructional training
belongs, and if a distortion, to identify the
nature of that distortion and how it might In self-instructional training, the members
interfere with social functioning and the elicit- are taught first in the face of a problematic or
ing of strong emotions. In the group the stress-inducing series of situations to utilize
members exchange their ideas until each person functional self-statements at each step of the
has a clear picture of what a cognitive distortion series. This process consists of step-by-step
is and why a given statement is a cognitive verbalizations concerning the problem defini-
distortion. tion (ªWhat's wrong with the way I'm thinking
Later using the theoretical framework they about this?º), problem focus (ªWhat can I do
have learned, they are better able to identify about it?º), focusing of attention (ªI should
their own unique patterns of cognitive distor- think about how that will get me in trouble.º),
tions, dysfunctional thinking, or illogical ex- coping statements (ªIf I keep relaxing I won't
pectations and those of their peers. Continuing blow it!º), and self-reinforcement (ªWow! I did
with the above exercise the clients are asked to it! See, I can do it!º). In groups, the members are
identify one statement they are likely to make trained in the method first by providing the
which they might be identified as a cognitive members with a model. Examples of situations
distortion. To help each other in the process of in which self-instructional training would be
appropriate are the following: (i) a situation in relaxation is a coping target in its own right. The
which a person is unfairly critizing the patient training involves teaching patients a modified
and escalates the criticism over time; (ii) a version of the alternate tension and relaxation
situation in which the patient is being persis- technique (developed by Jacobsen, 1978, and
tently hassled to do something she does not adapted by Bernstein & Borkovec, 1973) and
want to do; and (iii) a situation in which a then later fading the tension phases. Various
person must make a presentation to colleagues alternatives uniquely suited to various popula-
and others of which he has little experience. If a tions are also taught. Modest research support
given member identifies such a situation, the for the use of relaxation procedures in reducing
members brainstorm coping self-statements the anxiety and stress is to be found in studies by
given patient might make in the several steps Stovya (1977) and Lyles, Burish, Korzely, and
involved in learning to cope with the situation. Oldham (1982). However, Heide and Borkovec
A group member models the statements (1983) warn that for a few persons relaxation
(cognitive modeling) for the given patient who may increase anxiety. In groups the members
then practices the same statement (cognitive are taught the procedures by the therapist
rehearsal). The given patient is assigned the task modeling the procedure then by having them
of self-monitoring how he or she handles the practice the procedures a few muscle groups at a
given situation should it occur, and reports his time. Once the therapist has relaxed the entire
or her experience back to the group. Often this group together, in order to make use of the
method is combined with social skill training. group, the members then go through the same
Other methods with cognitive as well as procedures with each other in pairs. The
behavioral elements used in groups are thought therapist prompts the ªteachersº and monitors
stopping in the face of persistent recurring the process and is available if someone gets
thoughts, systematic desensitization or exposure stuck. This affords each member the opportu-
methods in the case of phobias, and guided nity to be both teacher as well as learner. The
imagery. Gradual exposure methods have been members are given tapes and encouraged to
used in the treatment of agoraphobia (Hand, practice the relaxation out of the group, if
Lamontagne, & Marks, 1974) and obsessive- possible with a ªbuddyº so that they can
compulsive disorder (Fals-Stewart et al., 1993) monitor each other's practice. In addition,
with positive results. In the treatment of meditation (Carington, 1978) and diaphrag-
agoraphobia the group members accompanied matic breathing in some groups are taught as
each other to face the feared setting together. alternatives to deep muscle relaxation.
The group served as support and encouragement
for each other. Later the members accompany
one person at a distance and eventually each 6.15.4.5 Reinforcement and Stimulus Control
patient faces the feared situation alone.
In the group treatment of obsessive-compul- These are not central methods in most
sive disorder (OCD), Fals-Stewart et al. (1993) applications of CBIGT except in parent training
used both exposure to the feared object (e.g., groups where the parents are taught to modify
dirty materials, garbage cans, etc.) and response antecedent conditions and consequences with
prevention (e.g., by preventing the individual their children. Reinforcement is derived from
from washing their hands for at least an hour operant theory and involves the target person
after exposure to a contaminant). Where in vivo performing a target behavior followed by a
exposure was not feasible, imaginal flooding reinforcing event (positive reinforcement) or the
was used. This combination seemed to be withdrawal of an aversive stimulus (negative
effective in alleviating OCD symptoms of reinforcement). Both forms of reinforcement
patients in groups as well as in individual increase the probability that the target behavior
therapy. The groups are used effectively because will increase under similar conditions in the
of the multiple modeling effect. Also members future. Stimulus control involves procedures in
can help plan each other's hierarchy of anxiety- which the immediate conditions which lead to
provoking activities with which they would or are parallel with a given behavior are changed
expect to be confronted in the near future. to create conditions more amenable to the
performance of a desired behavior. Creating
conditions in the group through subgrouping as
6.15.4.4 Relaxation Methods a means of getting broad participation is an
example of modifying the stimulus conditions.
These are strategies for helping patients to In groups patients receive many kinds of
cope with strong emotional responses such as reinforcement for the performance of prosocial
anger, stress, or depression. Thus, relaxation group behavior and the completion of extra-
training is an intervention and the skill in group tasks. With adults, this reinforcement
takes the form of praise by the group therapist useful to encourage physical movement (knock-
or other group members. Occasionally it takes ing at and opening imagined doors, sitting and
the form of smiles, applause, approving nods, standing when appropriate), separate the
and delighted laughter. Also reinforcement is an players clearly from the observers, give the
effective communication skill in its own right if observers a clear observational task, and to keep
carried out appropriately. Finally, high levels of the role-plays brief at least in the beginning.
mutual reinforcement have been shown to to Where patients are reluctant to participate, the
increase the cohesion of therapy groups (Gold- therapist will model role-playing with collea-
stein, Heller, & Sechrest, 1966). For these gues, write out scripts, and let members express
reasons every effort is made to include as much their thoughts with ªI would say . . . º before
reinforcement as possible in the early sessions. having them actually act it out. Usually in
Reinforcers can also be withheld in response to groups there are some members who are willing
undesirable behaviors. This is referred to as to try it out first and who consequently serve as
extinction and is an occasional response in models for the others.
groups when someone is frequently off-task or
complains a great deal. Extinction is difficult to
6.15.4.6.2 Subgrouping
perform in groups since it requires the coopera-
tion and prior agreement of all group members Subgrouping is a simple procedure of work-
along with the therapist. ing in pairs, triads, or other sized subgroups as a
means of increasing interaction among the
members and providing them an opportunity
6.15.4.6 Small-group Procedures to work without the constant oversight of the
therapist. Many of the group exercises are
Because CBIGT is also a small-group performed in subgroups. Subgrouping also
approach, it is possible to take advantage of creates an opportunity to practice leadership
the multiple interaction to enhance the effec- skills. Care is taken to assign subgroups with
tiveness of the intervention and assessment various compositions in order to avoid ªcliqueº
procedures described earlier and to provide formation which might work against the pursuit
entirely new ones. Since most group therapies of treatment goals. In working with subgroups,
make use of some of these techniques, only a few the therapist must give them clear assignments,
are illustrated in terms of their unique applica- the results of which they report back to the
tion in CBIGT. These include role-playing, the larger groups. He or she must also carefully
buddy system, subgrouping, leadership delega- monitor the activities of the subgroups to make
tion, and group exercises. (These and other sure they are working on the given tasks.
group procedures commonly used in CBIGT
are described in detail by Rose, 1989, as they
apply to adults and Rose, 1998a, as they apply 6.15.4.6.3 Buddy system
to children and adolescents.) The buddy system is a special subgrouping
procedure for patients to work together outside
of the group (see O'Donnell, Lydgate, & Fo,
6.15.4.6.1 Role-playing
1979, for a review of the research with children).
Role-playing is a set of procedures that has In CBIGT the buddy system is especially useful
several purposes in CBIGT. First it is used to in facilitating completion of the group tasks.
demonstrate or model behaviors targeted in Buddies check with each other on their
problem-solving and for the patient to practice respective progress and reinforce each other
(behaviorally rehearse) them before trying them for small successes. In addition to the advan-
out in the real world as part of the modeling tages mentioned above, it contributes to the
sequence discussed earlier. It is highly focused transfer of learning within the group to
and followed by highly specific feedback. Role- situations outside of the group.
playing may also used for assessment by having
a patient role-play a problem situation as much
6.15.4.6.4 Group exercises
as possible as it originally occurred. A set of
situations may also be presented to the patients Group exercises refer to the use of structured
who role-play their responses. It is also used to interactive activities as ways of teaching
teach specific therapy skills such as providing patients the skills which mediate the achieve-
constructive feedback and receiving critical ment of therapeutic goals. For example, an
feedback, and in generalization training to introduction exercise is used in which patients
practice preparing for an unsympathetic envir- interview at least two patients in the group and
onment or the eventuality of setbacks. When introduce them to the others. Another exercise
using role-playing, practitioners have found it is one in which the patients study a case and
discuss how each of them is different from the attainment. The responsibility for achieving a
person in that case. In stress groups an exercise change in group process cannot usually be linked
is used in which members identify their own to a change in behavior of any one member or the
unique stress response (see Rose, 1998, for a group therapist, but to interactive changes
list and description of commonly used ex- among all or most of the members and the
ercises, most of which can be used with adults therapist. Several problems in particular stand
as well as children). Often the exercises are out such as when group cohesion is too low,
performed in part in subgroups of varying when the communication pattern primarily
sizes. Each exercise has a rationale, a stated directly from members to the therapist and
purpose, and a set of instructions for indivi- not to each other, when self-disclosure is too low,
duals and for the group as whole. In one when some members dominate the interaction
particular application of CBIGT, exercises are while others are virtually excluded, when
used in every session. The exercises serve to antitherapeutic norms exist such as a pattern
provide variation in program, enhance interest of lateness, and where members are frequently
and cohesion, and create opportunities for off-task. In general, most of these group
broad participation. problems are avoided by careful treatment
programming. Occasionally when a group
problem persists, it is necessary to use systematic
6.15.4.6.5 Group feedback problem-solving.
Group feedback is another group technique The therapist points out the problem as he or
that plays an important role in group therapy. she experiences it and checks with the group if
Members are constantly giving each other they perceive it. Often the therapist can back up
feedback as to what they do well and what his or her perception by the results on the
they might consider doing differently. In postsession questionnaire or other ongoing
CBIGT the patients are trained in how to give measurement procedure. If in discussing the
feedback in such a way as to maximize its problem, blame is laid at the feet of the therapist,
positive reception. The criteria which the one member, or one subgroup, the therapist
participants are trained (in exercises) to use points out that the problem cannot exist without
are to give positive feedback first, describe what the shared contribution of all members and the
was done in specific terms, and use an I therapist. It requires a change in behavior or
statement. In giving critical feedback the attitude of everyone. If the group agrees, the
members are asked to affix the word, ªwhat I members are asked to brainstorm what the
might do differently is . . .º or ªone thing you group can do, what each member him- or herself
might consider doing differently is . . .º In order can do, and what the therapist can do to
to protect the recipient of feedback, he or she ameliorate the problem. Then the group uses the
can stop feedback any time he or she chooses. ideas to negotiate a group plan and a therapist
Even with these protections the therapist must plan and each person commits him- or herself to
be careful to monitor feedback to make sure an individual plan all of which are found in the
that no one is being devastated by what he or she following example.
hears. Usually the norms of giving helpful
In a hospital group of patients with borderline
feedback are quickly established and the group personality disorders, the therapist noted that
members correct inappropriate feedback when- everyone seemed to be addressing all their ques-
ever it should occur. The group members in tions to her and not to each other, in spite of the fact
contrast with the individual therapist provide a that many of them knew the answers better than the
wide range of diverse observations and feed- therapist. The co-therapist had been noting the
back. The danger of multiple comments being direction of all interaction at the past session and
too destructive or aversive can be limited by provided the group this information. The group
training the members receiving and giving members agreed, stating that it was easier, some-
feedback and by careful monitoring by the how, to do that, and besides she had the most
power. The therapist pointed out that eventually
group therapist.
they would have to depend on their own resources
and those of their peers, and this was a good
opportunity to practice solving a problem. Since
6.15.4.7 Identifying and Resolving Group the group members agreed with her assessment, she
Problems suggested that everyone write down one idea as to
what the group could do differently, what the
In all groups one can observe a number of therapist could do differently, and what each of
group problems. These can be defined as an them could do differently. An extensive list for each
intragroup interactive event (or series of events) category was generated, and after an evaluation,
or a product of interactive events which interfere the group selected for the group that whenever a
with effective member task performance or goal question is asked, everyone would write down what
they each thought was the answer. Then the person had encountered the previous week and had
asking the question would ask the others what they recorded in their diaries. For example, Laura told
had written. They agreed that the therapist would about a commonly occurring situation in which
throw back to the group any question directed to she felt upset by the half joking way in which her
her and remind them of the agreement. The boss implies criticism of her in front of others but
individual plans included relaxing before the ses- never states it. She always felt anxious at work and
sion and before answering a question, looking at constantly afraid he would criticize her at any time.
other members instead of the therapists, and The other members by asking questions helped to
listening more carefully to each question asked spell out the details of the situation and to relate it
by writing down the question. to other situations in which she is also often quite
anxious. They also examined her thoughts in these
situations. In each situation, the group suggested
6.15.4.8 Phases of Group Development how her self-defeating statements, ªI can't stand
being criticised,º ªIf I'm criticized, I must be an
Many of these group problems are a function awful personº seem to keep her in a state of
of the phase of group development in which the constant anxiety and she agreed that something
group finds itself. Group development refers to must be done about these cognitions and some
the ways in which norms, roles, cohesion, action with respect to her boss was called for.
communication patterns, subgroups, and lea- Based on suggestions generated through ªbrain-
dership shift over time. In that sense group stormingº from the group, she decided to do two
development is a kind of metaprocess. Common things differently. First, she would let her boss
elements seem to run through most paradigms of know that she was dissatisfied (while reminding
group development (see e.g., Corey & Corey, herself that she was a highly regarded employee
and she was willing to risk any potential fall-out)
1997; Forsyth, 1990; Garvin, 1987, pp. 110±111; with his public suggestion of criticism; if he had
Sarri & Galinsky, 1985; Tuckman, 1965), which any criticism she would like to hear it explicitly
suggest that some phenomena are at least in stated in private. Whenever she began to feel
part a function of time. It is useful for group negative about herself, she would take a deep
therapists to be aware of group process insofaras breathe and relax. In order to prepare Laura to
the phase of therapy is one of many conditions carry out the solution, several members of the
which may contribute to the appearance of group demonstrated in a role play how she might
certain behaviors viewed as obstructionist or act with her boss, and then she rehearsed what she
constructive such as one might experience in the would actually say first to herself and then aloud to
conflict phase. her boss. Then several members demonstrated
how, when confronted with implied criticism, what
In Table 2 these often overlapping phases are she might think to herself and say aloud to her
differentiated into the phase of development, boss. Laura also rehearsed her thoughts and her
the therapist activity, and the observable group actions until she indicated she was comfortable
phenomena. with the way she handled them. Most of the other
members handled a similar stress inducing situa-
tion with emphasis on the cognitions that pre-
6.15.4.9 Integrating Diverse Intervention vented them from dealing with them.
Strategies in CBIGT Towards the close of the session, all the
members designed with a partner their new extra-
In the following example the way in which group task and announced it to the group. For
various intervention strategies are developed example, Laura reported that she would make an
into an integrated treatment package in CBIGT appointment with her boss and then carry out the
are examined. plan developed earlier in the session. She would
also monitor her self put-downs and her self-praise
In the fourth session of a stress management group statements throughout the following week (which
the therapist reviewed the postsession data from the she has been working on for several weeks) and
previous week. He noted that satisfaction and a practice relaxation at least four times for 15
feeling of self-control of the activities of the group minutes each time. After the others also reported
had showed a lot of improvement over the previous a plan for their extragroup task, they practiced
session and the members agreed that that was a relaxation (all had problems with handling strong
good sign. Then the therapist asked each member to emotions) in pairs. The session was closed by
review what he or she had done on the extragroup filling in the postsession questionnaire.
tasks during the week. Applause and cheers greeted
those who completely or partially succeeded. Although sessions vary considerably, the above
A group exercise was used to train all the
session is typical insofaras previous extragroup
members in correcting the cognitive distortions
that they had identified the previous week in the tasks are monitored, the results of the postses-
first part of the exercise. In this exercise each sion questionnaire are reviewed and evaluated,
person eventually identified one distortion that a group exercise is carried out, problematic
each usually made. Following the exercise, each situations are presented by most of the members
member brought in a stressful situation he or she of the group, alternative responses to those
situations are generated, cognitive and overt of depression in disadvantaged women. Women and
modeling of the alternative responses takes Therapy, 18(3±4), 91±105.
Bandura, A. (1977). Self-efficacy: Toward a unifying
place, the members practice cognitive and theory of behavioral change. Psychological Review, 84,
behavioral alternatives for which they receive 191±215.
group feedback, cognitive distortions the client Beck, A. T. (1976). Cognitive therapy and emotional
may have had in relation to the situation are disorders. New York: International Universities Press.
Beck, A. T., & Emery, G. (1985). Anxiety disorders and
considered, relaxation is practiced, and extra- phobias. New York: Basic Books.
group tasks are planned. The group was used in Bernstein, D. A., & Borkovec, T. D. (1973). Progressive
many ways: the use of role-playing, subgroups, relaxation training: A manual for the helping professions.
the generation of ideas, group exercise, group Champaign, IL: Research Press.
feedback, and the structuring of broad partici- Bottomley, A., Hunton, S., Roberts, G., & Jones, L.
(1996). A pilot study of cognitive behavioral therapy and
pation. All were integrated into a coherent and social support group interventions with newly diagnosed
fast-moving session. cancer patients. Journal of Psychosocial Oncology, 14(4),
65±83.
Cardillo, J. E. (1994). Goal setting, follow-up, and goal
6.15.5 SUMMARY AND CONCLUSION monitoring. In T. J. Kiresuk, A. Smith, & J. E. Cardillo
(Eds.), Goal attainment scaling: Applications, theory, and
Some of the research supporting the use of measurement (pp. 39±59). Hillsdale, NJ: Erlbaum.
Carrington, P. (1978). Learning to meditate: Clinically
CBGT with various populations has been standardized meditation (CSM). Course workbook.
reviewed. It appears that group therapy is as Kendall Park, NJ: Pace Educational Systems.
effective as individual therapy and more Comas-Diaz, L., & Duncan, J. W. (1985). The cultural
efficient. It is also more effective than doing context: A factor in assertiveness training with mainland
nothing and several other alternative therapies. Puerto Rican women. Psychology of Women Quarterly,
9, 463±475.
Follow-up information is either limited or Corey, M. S., & Corey, G. (1997). Groups process and
reveals little maintenance. Most of the research practice (5th ed.). Pacific Grove, CA: Brooks/Cole.
on CBGT does not report on any use of the D'Zurilla, T. J. (1986). Problem-solving therapy: Social
group beyond it being the context of treatment. competence approach to clinical intervention. New York:
In this chapter the reader has been presented Springer.
D'Zurilla, T. J., & Nezu, A. M. (1988). Development and
with one type of cognitive-behavioral group preliminary evaluation of the social problem-solving
therapy in which use is explicitly made of the inventory. Paper presented at AABT, New York.
group. The various assessment, intervention, Ehlers, A., Stangier, U., & Gieler, U. (1995). Treatment of
and generalization strategies employed in atopic dermatitis: A comparison of psychological and
dermatological approaches to relapse prevention. Jour-
CBGT have been presented specifically as they nal of Consulting and Clinical Psychology, 63(4),
could be uniquely applied in a group and which 624±635.
take advantage of the group context. Specific Ellis, A. (1973). Humanistic psychotherapy. New York:
group interventions are identified. The corner- McGraw-Hill.
stone of using the group is maximum involve- Enright, S. J. (1991). Group treatment for obsessive-
compulsive disorder: An evaluation. Behavioural Psy-
ment of the members in the treatment process chotherapy, 19(2), 183±192.
both as patient and as cotherapist. Because of Fals-Stewart, W., Marks, A. P., & Schafer, J. (1993). A
the focus on interaction, this particular ap- comparison of behavioral group therapy and individual
proach to CBGT has been referred to through- behavior therapy in treating obsessive-compulsive dis-
order. The Journal of Nervous and Mental Disease,
out as cognitive-behavioral interactive group 181(3), 189±193.
therapy or CBIGT. Flowers, J. V., & Schwartz, B. (1985). Behavioral group
It is clear that intense involvement of therapy with clients with homogeneous problems. In S.
members in the therapeutic process is costly Ross & D. Upper (Eds.), Handbook of behavioral group
in time. Much less can be covered in a given therapy. New York: Plenum.
Forsyth, D. R. (1990). Group dynamics (2nd ed.). Pacific
number of sessions. According to our clinical Grove, CA: Brooks/Cole.
observations, failure to become involved often Gambrill, E. D., & Richey, C. A. (1973). An assertion
results in a highly didactic quality of therapy, inventory for use in assessment and research. Behavior
high drop-out rates, and lower levels of Therapy, 6, 550±561.
learning. More research on these very issues is Garvin, C. (1987). Contemporary group work. Englewood
Cliffs, NJ: Prentice-Hall.
required before one can be firmly committed to Goldstein, A. P., Heller K., & Sechrest, L. B. (1966).
this conclusion. Psychotherapy and the psychology of behavior change.
New York: Wiley.
Graff, R. W., Whitehead, G. I., & LeCompte, M. (1986).
6.15.6 REFERENCES Group treatment with divorced women using cognitive-
behavioral and supportive-insight methods. Journal of
Abraham, I. L., Neundorfer, M. M., & Currie, L. J. (1992). Counseling psychology, 33(3), 276±281.
Effects of group interventions on cognition and depres- Hand, I., Lamontagne, Y., & Marks, I. M. (1974). Group
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196±202. Journal of Psychiatry, 124, 588±602.
Azocar, F., Miranda, J., & Dwyer, E. V. (1991). Treatment Heide, F. J., & Borkovec, T. D. (1983). Relaxation-induced
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6.16
Affective Disorders
ROBERT J. DeRUBEIS, PAULA R. YOUNG,
and KATHERINE K. DAHLSGAARD
University of Pennsylvania, Philadelphia, PA, USA

6.16.2 PHENOMENOLOGY 340
6.16.2.1 Phenomenology of Depressive Episodes 340
6.16.2.2 Phenomenology of Manic Episodes 341
6.16.3 CLASSIFICATION 342
6.16.3.1 Unipolar±Bipolar Distinction 342
6.16.3.2 Melancholic±Nonmelancholic Distinction 342
6.16.3.3 Seasonal±Nonseasonal Distinction 343
6.16.4 ETIOLOGICAL FACTORS 344
6.16.4.1 Epidemiology 344
6.16.4.1.1 Epidemiology of unipolar disorder 344
6.16.4.1.2 Epidemiology of bipolar disorder 345
6.16.4.2 Genetics 345
6.16.4.2.1 Genetics of unipolar disorder 345
6.16.4.2.2 Genetics of bipolar disorder 346
6.16.4.3 Life Events 347
6.16.4.3.1 Life events in unipolar disorder 347
6.16.4.3.2 Life events in bipolar disorder 348
6.16.4.4 Effects of Early Environment on Unipolar Disorder 348
6.16.5 COMORBIDITY 349
6.16.5.1 Comorbidity with Anxiety Disorders 349
6.16.5.2 Comorbidity with Substance Use Disorders 350
6.16.6 SUICIDE 351
6.16.7 THEORIES AND TREATMENTS OF UNIPOLAR DISORDER 352
6.16.7.1 Biological Theories and Treatments of Unipolar Disorder 352
6.16.7.2 Cognitive Theories and Treatments of Unipolar Disorder 354
6.16.7.3 Behavioral Theories and Treatments of Unipolar Disorder 356
6.16.7.4 Psychodynamic Theories and Treatments of Unipolar Disorder 357
6.16.8 THEORIES AND TREATMENTS OF BIPOLAR DISORDER 358
6.16.8.1 Biological Theories and Treatments of Bipolar Disorder 358
6.16.8.2 Psychosocial Theories and Treatments of Bipolar Disorder 359
6.16.9 SUMMARY AND FUTURE DIRECTIONS 360
339
340 Affective Disorders
6.16.1 INTRODUCTION that genes play a substantial part in the

development of depression and mania.
The array of human problems which has come Note that brand names given in this chapter
to be known as the affective disorders offers refer to the most commonly prescribed brands
students of psychopathology an engrossing in the USA. Brand names other than those
course of study. The modern conception of this mentioned here are also used in the USA as well
nosologic category encompasses both depres- as internationally.
sion and mania, disorders in which the most
basic human drives and desires are altered, in
many cases to such a degree that life itself is 6.16.2 PHENOMENOLOGY
threatened. Hunger is extinguished, or in some
The phenomena that make up affective
cases excessive. Sleep is severely disrupted.
disorders form classic syndromes in that a wide
Sexual appetite evaporates or goes out of
array of distinctive experiences (symptoms) and
control. And the desire to live, taken for granted
behaviors (signs) are found to appear together
by most people most of the time, can be replaced
to form coherent clusters. Though disturbed
by the urge to die. Secondary drives and motives
mood is usually a central feature in a person
suffer as well. Achievement strivings, pride, and
who is diagnosed with an affective disorder
a sense of belonging in a social network become
(sadness in depression; euphoria in mania),
distant memories if they are remembered at all,
these symptoms are not required for either
or they are perceived out of proportion to reality.
diagnosis. Instead, the person must possess a
Nearly all of psychology's philosophical,
collection of phenomenologically disparate
methodological, and scientific battles have
signs and symptoms. The system embedded in
taken place in the field of the affective disorders.
the fourth edition of the Diagnostic and
Although many of the secrets of the affective
statistical manual of mental disorders (DSM-
disorders have yielded to scientific inquiry, and
IV; American Psychiatric Association [APA],
there is little controversy about the nature and
1994) will be used to describe the syndromes of
treatment of mania, uncertainties regarding
major depression and mania.
many of the most basic issues in depression
remain. Is the distinction between a sad mood
and major depression one of degree or of kind? 6.16.2.1 Phenomenology of Depressive Episodes
Is depression essentially psychological or bio-
logical in nature? To what degree is it caused by Modern diagnostic systems recognize a dis-
genetic factors, and to what degree by environ- tinction between short-term emotional upset
ment? Of the environmental influences, is the and a major depressive episode, in part by
key factor childhood upbringing, or is it a requiring the presence of the depressive syn-
difficult environment encountered in adult- drome over a period of time. Two weeks has
hood? And finally, which are the more effective been chosen as a reasonable if arbitrary cutoff.
treatments for depression: biological or psy- Moreover, the depressive syndrome is not
chological ones? The answers to each of these considered to be present if the signs and
questions are complex, but with the enormous symptoms can be accounted for by a normal
amount of research conducted since the 1960s, bereavement reaction, a medical condition, or a
the field is moving closer to an integrated reaction to a medication or a drug of abuse. In
understanding of depression and its treatment. this way, the depressive syndrome designation is
In the last four decades the field has also reserved for cases in which the appearance of
witnessed several new discoveries and the depressive signs and symptoms is neither
development of potent treatments for the normative nor readily explained by gross
affective disorders. With the exception of somatic disturbance.
electroconvulsive therapy, none of the treat- The DSM-IV requires that, for a major
ments used 40 years ago are among those depressive episode, either sadness or lack of
considered effective today. Specific antidepres- interest/pleasure be present most of the day,
sant medications, as well as targeted psychoso- each day. Sadness is usually a reported
cial interventions, have been added to the list of symptom, but its presence can be inferred from
effective treatments. A newly described variant crying spells or from facial expression. Dimin-
of affective disorder, seasonal affective disorder, ished interest in activities can be obtained from
has led to the development of light therapy, a the patient's subjective report, or it can be
treatment that would have been the stuff of inferred from reduced participation. Markedly
science fiction 25 years ago. Advances in reduced interest in sexual activities is common.
genetics have not yet informed our under- The vegetative symptoms, especially sleep
standing of the biological processes involved in and appetite disturbance, are seen by many as
the affective disorders, but we now understand the essential indicators of depression. The
Phenomenology 341
classic forms of these disturbances entail sleep depressive illness articulated by Kraepelin
loss (insomnia) and a decreased appetite (1921) in the early part of the twentieth century.
(hypophagia), but it is now widely recognized These descriptions continue to be some of the
that the reverse, hypersomnia and hyperphagia, most illustrative accounts of the phenomenol-
are commonly found in persons with the other ogy of mania.
symptoms of the depressive syndrome. Thus, The central feature of a manic episode is a
these reversed vegetative signs are included in distinct change in mood. This change can be
the most recent diagnostic systems and assess- reflected in either an elevation of mood (elation,
ment tools. Persons whose affective episodes euphoria), or in irritability. Elevated mood may
follow a seasonal pattern (see Section 6.16.3.3) be inferred by behaviors such as joking, laughing
are particularly likely to experience these and singing. Euphoria is not necessarily per-
reversed vegetative symptoms. ceived as problematic by the patient. DSM-IV
The motor symptoms of agitation and requires that the change in mood lasts for at least
retardation are especially observed in the more one week, or less if the impairment is severe
severe forms of the syndrome. Agitation is enough to warrant hospitalization. Dysphoria
manifest in pacing or fidgeting, and the (sad mood) may occur within a manic episode,
experience that it is difficult to sit still. and there may be frequent changes between
Psychomotor retardation is observed in slowed elation and depression. Persons with this pattern
speech and movements, and is reported as the have been labeled dysphoric manics, or as those
feeling of moving in slow motion. Depressed having a mixed episode (Post et al., 1989).
patients also report fatigue and reduced energy Inflated self-esteem and grandiosity are
that cannot be attributed entirely to either sleep characteristics of mania. The manic person
deprivation or diminished interest. often has an exaggerated sense of achievements
Cognitive symptoms are also observed in and abilities. Grandiosity may also be observed
depression: excessive self-blame or guilt, along in the manic person's behavior, such as
with the belief that one is inadequate or embarking impulsively on ambitious but un-
unworthy, are nearly always present. Such realistic projects, or giving advice on matters
beliefs can become so unconnected to reality about which he or she has little knowledge. The
as to be delusional. Extreme pessimism about grandiosity may also manifest in delusions, such
the future, a state referred to as hopelessness, is as a belief that one is a deity or a famous public
also common. figure.
Depressed persons often report great diffi- Increases in energy are observed in mania. In
culty with concentration and decision-making. earlier stages and milder forms of mania, this
Simple acts such as reading the newspaper, may manifest in increased goal-directed activ-
following a conversation, or watching televi- ities in social or occupational realms, some of
sion, can become virtually impossible for the which may be successful. In later stages, manic
severely depressed person. Problems with con- persons may be unable to sit still, and they may
centration and decision-making result in part initiate many tasks that they are unable to
from the distraction caused by persistent complete because of severe distractibility. The
worries, but they also reflect cognitive ineffi- increase in activities may include imprudent
ciency, possibly associated with hormonal involvement in pursuits of pleasure which have
disturbance (Rubinow, Post, & Savard, 1984). high potential for painful or dangerous con-
Depressive disorders also include milder sequences. Increased sexual drive can lead to
forms, which are nonetheless bothersome en- impulsive and reckless sexual behavior, such as
ough to warrant attention and treatment, infidelity or sexual encounters with strangers.
especially when they are experienced over long Buying sprees that involve expensive, unneeded
periods of time. Dysthymic disorder refers to items, gambling binges, or foolish business
long-lasting episodes of mood disturbance that investments create financial problems, which
are not severe enough to qualify as a major can exacerbate subsequent depressive episodes.
depressive episode. For a person to be deemed Decreased need for sleep is common. Fo-
dysthymic, mild to moderate levels of depressive garty, Russell, Newman, and Bland (1994)
symptoms need to be experienced most of the reported reduced sleep as the most frequent
day, more days than not, over a two year period symptom in those with a history of mania. The
(APA, 1994). sleep disturbance seen in mania differs from that
observed in depression; in mania, the distur-
bance is related to a marked decrease in
6.16.2.2 Phenomenology of Manic Episodes perceived need for sleep. Some manic indivi-
duals go for days without any sleep, yet they
Modern conceptions of manic syndromes report no fatigue. By contrast, in depression the
have their roots in the descriptions of manic decreased sleep (insomnia) is unwanted, and the
restless sleep that does occur is not experienced both poles of affective disturbance. The use of
as restorative. the term ªmanic-depressiveº is today more a
The disturbed thought processes of mania are source of confusion, since it implies that one
distinct and can be readily observed in the speech suffering from it would have experienced (or
of the manic patient. The rate of speech is rapid; could expect to experience) both mania and
interrupting the manic patient can be difficult. depression.
Speech is often colorful, and characterized by the In more modern classification systems this
use of rhymes, puns, and word associations confusion has been eliminated. Separate cate-
based on sounds rather than meaning (clang gories have been recognized for (i) patients who
associations). Persons in a manic episode may have experienced only depressive episodesÐ
report that thoughts are racing through their unipolar disorder; and (ii) patients who have
mind. The thought disorder characteristic of experienced both manic and depressive
mania, which is reflected in the content of speech, episodesÐbipolar disorder. There was some
is known as ªflight of ideas.º Speech may be concern that a third category, for patients who
tangential, or there may be frequent, loosely experienced only manic episodes, would be
associated shifts from one topic to another. needed, but research on the treatments, genetics
Individuals in a manic episode are characterized and clinical courses of these patients has shown
by their inability to screen out irrelevant stimuli, that they are best considered bipolar, rather
both internal (thoughts) and external (sights, than unipolar manic, despite the absence of a
sounds). This distractibility can be observed in depressive episode. The organization of much of
the quickly shifting speech content and activities this chapter recognizes the importance of the
of the manic individual. The symptom known as unipolar±bipolar distinction. Differences be-
ªpressured speechº refers to the forced quality of tween unipolar and bipolar disorders have been
utterances. It is experienced by the manic person found in regard to (i) epidemiologic factors,
as an inability to slow down or inhibit speech. including gender distributions; (ii) genetics; (iii)
Psychotic symptoms such as delusions or psychosocial causes; (iv) course of illness; (v)
hallucinations are present in more than half of biologic variables; and (vi) treatments.
manic patients (Silverstone & Hunt, 1992). Perris (1992) reviewed findings from family
Delusions in mania tend to be grandiose, but studies, twin studies, and adoption studies that
paranoid delusions are not uncommon. Hallu- together support the claim that unipolar and
cinations are most frequently auditory, and are bipolar forms of affective disorder are, at least
usually congruent with prevailing mood and to some degree, genetically distinct. In the
themes of grandiosity. family studies, unipolar (or bipolar) probands
were identified, and their first-degree relatives
were assessed for the presence of unipolar or
6.16.3 CLASSIFICATION bipolar disorder. The mean morbidity risk for
bipolar disorder across seven family studies of
The heterogeneity of the affective disorders
unipolar probands was less than 2%, close to
has led to numerous attempts to discern
the population risk, whereas the risk for
meaningful subcategories. The usual nosologic
unipolar disorder was considerably higher, at
aims of improving the search for causes and
15%. These figures can be contrasted with those
treatments have driven these efforts. The
obtained in 14 studies of bipolar probands. The
severity of depressive symptoms varies con-
mean risk was 9% for bipolar disorder, which is
siderably, from mild dysphoria to psychotic
much higher than the population rate. However,
forms. Moreover, the observed variation ap-
the risk for unipolar disorder was rather high
pears to be continuous. Meaningful distinctions
also, at 13%. Although some of the unipolar
have been made, however, with implications for
relatives in this last group may have been
etiology and treatment.
misdiagnosedÐearly episodes in bipolar dis-
order tend to be depressionsÐclearly the
6.16.3.1 Unipolar±Bipolar Distinction relatives of bipolar patients are at increased
risk not only for bipolar disorder, but for the
Of the many attempts to divide the affective unipolar form of affective pathology as well.
disorders into meaningful subclassifications, no
distinction has proven more fruitful than that
between unipolar and bipolar forms. Through 6.16.3.2 Melancholic±Nonmelancholic
the middle part of the twentieth century, Distinction
Kraepelin's (1921) diagnostic category of
ªmanic-depressive insanityº included all pa- The most enduring subtype within the
tients who experienced a manic or a depressive depressive spectrum has gone by several names,
episode, whether or not they had experienced but the use of ªmelancholicº to refer to the
Classification 343
classic presentation of depression has endured 6.16.3.3 Seasonal±Nonseasonal Distinction

through most of the twentieth century. The
concept, which has obtained inconsistent sup- Since the 1970s, increased attention has been
port from research findings, is that melancholic given to a subtype of affective disturbance that
(or endogenous) depressions are caused more by follows an annual patternÐseasonal affective
biological factors, and should respond better to disorder (SAD). An appreciation of this pattern
biological treatments, than their oppositeÐthe has led to important advances in its treatment,
so-called exogenous (or nonmelancholic, reac- and to an increased understanding of the
tive, or neurotic) depressions. biological mechanisms that play a role in all
There is indeed a melancholic symptom depressions. Moreover, the fact that some
pattern that coheres fairly well (Haslam & depressions follow a seasonal pattern has fueled
Beck, 1994), although the presence of endogen- an interest in the evolutionary function that this
ous symptoms is also indicative of, and may depressive complex might have served for our
simply reflect, a more severe form of depression. ancestors (Whybrow & Bahr, 1988).
Melancholic features include: early morning The typical annual course for SAD is an onset
awakening, weight loss, loss of pleasure, and in mid to late autumn, with either remission of
loss of reactivity to usually pleasurable stimuli. symptoms in early spring, or a period of
By contrast, a nonmelancholic pattern may hypomania or mania followed by a return to
involve no sleep or appetite disturbance, or a normal mood. The symptom pattern found in
reversed pattern, characterized by excessive SAD differs from that found in nonseasonal
sleeping and weight gain. In addition, such depressions. The ªreversed vegetative symp-
individuals often experience a lifting of mood in tomsº of hypersomnia (increased sleep) and
response to rewarding or pleasurable events in hyperphagia (increased appetite) are common.
their environment. In this regard, SAD is similar to another
Attempts to validate the melancholic± subtype of depressionÐatypical depression
nonmelancholic distinction have produced (Lam & Stewart, 1996); however, it differs from
mixed results. The assumption that melancholic atypical depression in important ways. Craving
(endogenous) depressions ªarise from within,º for carbohydrates, especially sweets, is pro-
and are therefore not likely to have been nounced in SAD, but not in atypical depression.
preceded by a negative life event, has not Interpersonal sensitivity and avoidance of
generally been confirmed with data (Grove & rejection are not common in SAD, but they
Andreasen, 1992). Most researchers have found are defining features of atypical depression
that plausible precipitating events are common (Tam et al., 1997). Lethargy and disinterest are
in both endogenous and exogenous depressions, especially common in SAD. The signs of SAD
although the association may be stronger in are thus akin to those observed in a hibernating
melancholia (Brown, Harris, & Hepworth, animal (Whybrow & Bahr, 1988).
1994). SAD is found predominantly in the higher
However, the endogenous±exogenous distinc- latitudes, such as in Scandinavian countries or
tion does predict response to biological treat- the southern parts of South America. It is
ments. Both electroconvulsive therapy and nonexistent near the equator, because light and
antidepressant medications are more effective climate conditions vary seasonally in the higher
for endogenous episodes than for episodes with a latitudes, but not in the lower. Separate
reactive symptom pattern (Grove & Andreasen, influences of light and temperature have been
1992). The ªbiological vs. non-biologicalº con- difficult to distinguish (Molin, Mellerup, Bol-
notation of this distinction would receive even wig, Scheike, & Dam, 1996), because they tend
more support if the reverse pattern were found to covary. Although it is possible that tempera-
for psychosocial interventions. There has been ture plays an independent role, it is believed that
little investigation of this question. Not one some aspect of exposure to light is critical for the
large-sample prospective comparison of biolo- development of SAD. Whether the critical
gical and psychological treatments has been variable is length of day (i.e., time from light
conducted, but results thus far have indicated onset to light offset), or total amount of light,
that psychosocial treatments such as cognitive has been difficult to determine.
therapy may not be as effective with melancholic Treatment for SAD involves therapeutic
depressions as they are with nonmelancholic exposure to high intensity light (see Tam,
depressions (Thase et al., 1996). Finally, biolo- Lam, & Levitt, 1995). Although most research
gical abnormalities associated with depression, has been conducted on light presented before 8
such as the dexamethasone suppression test, are a.m., the timing of the light treatment may not
found more often in melancholic than in matter for most patients (Meesters et al., 1993).
nonmelancholic depressed patients (APA Task The spectral properties of the light seem also not
Force on Laboratory Tests in Psychiatry, 1987). to be criticalÐwhite, red, green, and blue light all
appear to be equally effective. Intensity of light is ECA study. It appears, then, that findings from
important, howeverÐ2500 lux for one to two the earlier studies overestimated the prevalence
hours per day is a well-documented regimen, of unipolar depression. At this point, it would be
whereas less intense light (e.g., 500 lux) is not as safe to say that lifetime prevalence of major
effective (Tam et al., 1995). Briefer exposure depression in western societies is in the range of
(e.g., 30 minutes) with a higher intensity light 4±8%. However, this may be changing rapidly.
(10 000 lux) appears to be as effective as the Indeed, the most disturbing findings to emerge
standard treatment, lending credence to the view from depression research since the 1970s concern
that it is the total amount of light that falls on the indications that depression rates have been
retina which is critical in the development and increasing dramatically in industrialized cul-
treatment of SAD (Terman et al., 1990). tures during the twentieth century (Klerman &
What physiological mechanisms explain how Weissman, 1989). Klerman and Weissman
the absence of light can lead to depressive estimate that the birth cohorts born after World
symptoms? How can treatment that involves War II incur more risk for depression than
only the presentation of extra light alleviate cohorts born early in the twentieth century,
SAD? The answer lies in the fact that humans perhaps by a factor of five or more. The same
possess a tract of nerves that runs directly from data suggest that the mean age of onset has been
the retina to the hypothalamus, without passing decreasing sharply in the same time period.
through the visual cortex. Presumably, this Whereas the older studies yielded mean age-of-
nonvisual tract plays a role in the regulation of, onset figures in the 50s or 60s, recent estimates
for example, mood, appetite, and sleepÐ suggest a mean age of onset in modern
functions controlled by the hypothalamus. industrialized nations in the late 20s. The most
dramatic change in age of onset also appears to
have occurred in the cohorts born around the
6.16.4 ETIOLOGICAL FACTORS
time of World War II and later. It is impossible to
6.16.4.1 Epidemiology rule out conclusively all of the potential artifacts
in such findings, especially since most of the data
6.16.4.1.1 Epidemiology of unipolar disorder
rely on respondents' memories and their will-
Depressive disorders occur on a continuum ingness to report potentially embarrassing
from mild (dysthymic disorder) to very severe feelings and behaviors. However, the phenom-
(psychotic, melancholic forms), with no clear enon survives careful scrutiny. For example, the
thresholds marking the transition points. This same epidemiologic methods have been applied
has made it difficult to study the prevalence of in nonindustrialized cultures, and no increases in
depression across time and across settings, as depression rates over time have been observed.
well as across cultures. Since the 1970s, Even though Klerman and Weissman's estimate
epidemiological studies have benefited greatly of the increase in rates is almost certainly an
from the development of standardized assess- overestimate (Fombonne, 1994), there is little
ment methods, beginning with the criteria of doubt that depression is and will continue to be a
Feighner et al. (1972) in the USA, and the more common disorder than it was in our great-
Present State Examination (Wing, Cooper, & grandparents' day, when it was a rare disorder.
Sartorius, 1974) in the UK. In a review of Despite between-study and between-era dif-
studies that were conducted prior to the ferences in rates of depression, a consistent
development of these instruments, Boyd and finding is that women experience unipolar
Weissman (1981) reported estimates of lifetime depression at about twice the rate of men
prevalence of unipolar depression that ranged (Weissman & Klerman, 1985). Several explana-
from 3% to 18%. Most researchers now cite the tions have been advanced to account for the
newer Epidemiological Catchment Area study gender difference; it appears that it cannot be
(ECA; Weissman et al., 1988), a large, five-site explained by a reporting artifact, or by
community survey that employed the Diagnos- differential willingness to consult mental health
tic Interview Schedule (Robins, Helzer, Ratcliff, professionals. Women have been found to
& Seyfried, 1982) to determine DSM-III (APA, engage in more ruminative, self-reflective think-
1980) diagnoses. In the ECA, lifetime preva- ing when they experience a low mood, whereas
lence of unipolar (major) depression was men engage more often in distracting activities
estimated at 4.4%. A further 3.2% were found (Nolen-Hoeksema, 1987). Hormonal differ-
to suffer from the milder, chronic version of ences and differences in the traditional roles
depression, dysthymia (Gwirtsman, 1994). A adopted by men and women appear also to play
substantially higher estimate of major depres- a role in the gender discrepancy (Nolen-
sion (8%) was obtained in the recent, large Hoeksema, 1987; Weissman & Klerman, 1977).
Edmonton study (Spaner, Bland, & Newman, There has been a consistent and surprising
1994), with methods similar to those used in the lack of association between socioeconomic
Etiological Factors 345
status and depression in epidemiological in- episode was about 17 weeks (Wertham, 1928).
vestigations (Weissman et al., 1988). Likewise, Since somatic treatments have been available,
within Western societies, racial and ethic the average duration of an episode has
differences in rates of depression have not been decreased to 10 weeks (Coryell & Winokur,
observed. Marital status is associated with 1992). Bipolar disorder is a chronic, recurrent
depression, however. Married persons who illness. Most individuals with this disorder will
have never divorced have the lowest rates, experience more than one episode during their
followed by those who have never married. The lifetime (Goodwin & Jamison, 1990). There is
highest rates tend to be found for divorced evidence that the time from the onset of one
persons, especially those recently divorced. episode to the onset of the next (cycle length)
Although the nature of the causal relationships decreases for each subsequent episode (Good-
involved is unclear, there is good evidence that win & Jamison, 1990), and that each affective
the presence of a supportive relationship, such episode increases the probability of future
as can be found in a good, stable marriage, acts relapse (Keller, Shapiro, Lavori, & Wolfe,
as a buffer against environmental stressors 1982).
(Brown & Harris, 1978). Alternatively, the It is estimated that 13±20% of bipolar
interpersonal adjustment of depressed people patients are rapid cyclers. Rapid cycling
is found to be impaired (Barnett & Gotlib, describes a subgroup of bipolar patients who
1988). Thus, a portion of the relation of marital experience more than four affective episodes in
status to depression is undoubtedly due to the a year (Dunner & Fieve, 1974). Females are
damaging effects of depression on intimate more likely than males to exhibit rapid cycling
relationships, including marriages. (Goodwin & Jamison, 1990). Although rapid
cycling is present from the onset of illness in
about 20% of cases, the majority (80%) develop
6.16.4.1.2 Epidemiology of bipolar disorder
rapid cycling later in the course of the illness.
Bipolar illness is much less common than The fact that rapid cycling generally develops
unipolar depression. In the ECA study, the later in the course of the illness may reflect an
lifetime prevalence was of bipolar disorder was underlying pathophysiological mechanism,
1.2% (Weissman et al., 1988). Whereas depres- such as progressive kindling or sensitization
sion is more common among females than (Post, Rubinow, & Ballenger, 1986). Kindling
males, gender does not appear to be a significant refers to the process whereby alterations in
risk factor for bipolar illness. Results of the neurotransmitter systems, such as occur in
ECA study indicate that the prevalence of depression or mania, transform the brain so
bipolar illness is nearly equivalent in the two as to make it more vulnerable to dysregulation
genders, with a female:male ratio of 1.2:1 in the future.
(Weissman et al., 1988).
The average age of onset of bipolar disorder is
20. About one in four bipolar patients experi- 6.16.4.2 Genetics
ence their first affective episode prior to age 20
6.16.4.2.1 Genetics of unipolar disorder
(Goodwin & Jamison, 1990). ECA data (Weiss-
man et al., 1988) indicate that incidence of Progress in the behavior genetics of depres-
bipolar affective disorder was highest in the sion has lagged behind that of similar work in
sample of 18±44 year olds (1.4%), and that there schizophrenia. However, there have been en-
were virtually no cases reported in the group ough replications of well-conducted family
aged 65 and over (0.1% incidence). studies and twin studies to warrant the conclu-
It is estimated that in just over half of bipolar sion that risk for unipolar depression is, at least
patients, the illness commences with a manic in part, heritable. From family studies it is
episode. On average, manic episodes develop estimated that the risk to first-degree relatives of
within a few days, whereas depressive episodes depressive probands is 11±18%, compared to
develop less abruptly, usually within a few 0.7±7% for relatives of normal controls (Mol-
weeks. Manic episodes are also shorter in din, Reich, & Rice, 1991). The higher figures
duration than depressive episodes (Keller within each of these ranges more likely
et al., 1986; Goodwin & Jamison, 1990). Gender correspond to the thresholds employed in
differences in the course of the illness have also modern estimates of population risk cited in
been examined. Manic episodes were predomi- the earlier section on epidemiology in this
nant in males with bipolar illness, whereas chapter. The main advantage of family studies
depressive episodes were more frequent in over other behavior genetic investigations is
females (Coryell et al., 1989). their large sample sizes (usually in the hun-
Prior to the advent of effective drug treat- dreds). The drawback is that, although findings
ments, the average natural duration of a manic from family studies can reveal general familial
risk, they cannot distinguish genetic from In part due to the difficulty of ascertaining
environmental contributions. cases of unipolar depression, and because the
Findings from twin studies can help to environmental contribution to risk is substan-
disentangle genetic from environmental factors. tial, efforts to identify the mode of genetic
There have been five twin studies completed in transmission for unipolar depression, and to
which the concordance rates in monozygotic identify the specific genes involved, have not
(MZ) twins have been compared to the been successful (Moldin et al., 1991). It appears
concordance rates in dizygotic (DZ) twins. that for the time being, biologically oriented
The greater the ratio of MZ concordance to researchers will need to focus on the biological
DZ concordance, the stronger the evidence for a markers and treatments for depression, know-
genetic contribution to depression. In each of ing that genes play some role. An understanding
the studies (Allen et al., 1974, Kallman, 1953, of the ways in which genes play their role awaits
Slater, 1953 [pooled together in Allen, 1976]; refinements in the ascertainment of unipolar
Bertelsen et al., 1977; Torgersen, 1986; all cited depression and its subtypes.
in Nurnberger & Gershon, 1992), the MZ
concordance was higher than the DZ rate. The
6.16.4.2.2 Genetics of bipolar disorder
MZ:DZ ratios ranged between 2.3:1 and 3.4:1,
suggesting a substantial genetic contribution to The primary etiologic understanding of
unipolar depression. bipolar disorder is that it is transmitted
In behavior genetic work, adoption studies are genetically. Belief in the heritability of bipolar
critical because they can help rule out confounds disorder is buttressed by findings from family,
that remain in even the best family and twin twin, and adoption studies. More recently,
studies. Only four adoption studies have been studies of genetic linkage and genetic associa-
conducted, however, in which unipolar depres- tion have been conducted. These are attempts to
sion was a focus of investigation. Although three identify specific genes that play a part in the
of the four studies (Cadoret, 1978; Mendlewicz & pathogenesis of bipolar illness.
Rainer, 1977; Wender et al., 1986) yielded Studies of families have consistently shown
findings consistent with a genetic hypothesis, that the prevalence of affective disorders (both
very small sample sizes (Cadoret) or very low unipolar and bipolar) are higher in the families
rates of unipolar illness in the sample (Wender of patients with bipolar disorder than in families
et al.) reduce confidence in two of them. of nonpsychiatric controls. When relative risk
Furthermore, Mendlewicz and Rainer did not factors are calculated (ratio of the risk in
distinguish unipolar from bipolar adoptees in relatives of probands to risk in relatives of
their study, although they did ascertain the controls), family studies of bipolar disorder
polarity of the biological and adoptive relatives. produce relative risk values upwards of 15 for
Finally, von Knorring, Cloninger, Bohman, and bipolar disorder, and between two and five for
Sigvardsson (1983) found no differences in the unipolar illness (Alda, 1997). Findings from
rates of unipolar depression between biological these studies have also suggested that the
and adoptive relatives of unipolar adoptees. various forms of affective illness are related in
Surprisingly, these null findings extended to a hierarchical wayÐrelatives of bipolar pro-
comparisons between the relatives of unipolar bands have increased risk for both bipolar and
adoptees and the relatives of control adoptees, unipolar disorder, whereas relatives of unipolar
despite a rather robust sample size. probands tend only to have increased risk for
To summarize, the evidence of a genetic unipolar illness (Perris, 1992).
contribution to unipolar depression has been Studies of twins have also provided substan-
inconsistent, and weaker than the evidence for tial evidence for the heritability of bipolar
several other mental disorders, including bipo- illness. Bertelsen, Harvald, and Hauge (1977)
lar disorder. McGuffin and Katz (1989) point observed an 80% concordance for bipolar
out that the inconsistencies in findings across disorder in MZ twins. Overall concordance
genetic investigations of unipolar depression rates for bipolar disorder are estimated at 57%
may arise from differences in the definition of for MZ twins, as compared to 14% for DZ twins
depression used in the various investigations. (Alda, 1997). Moreover, the concordance rates
They cite evidence that as one moves from the of MZ twins reared apart do not differ from
more severe forms of affective disorder (includ- those reared together (McGuffin & Katz, 1989).
ing bipolar disorder) to the moderate forms, and Results of adoption studies are consistent
finally to the milder, or neurotic forms, genetic with family study data (McGuffin & Katz, 1989)
contribution diminishes, whereas the contribu- Mendlewicz and Rainer (1977) have conducted
tions of both familial (common to all members the largest adoption study of bipolar probands.
of a family) and non-shared (unique to the For biological relatives of bipolar patients who
individual) environments increase. had been adopted away from their biological
parents, the risk was similar to that of relatives Researchers have investigated what types of
of bipolars who were not adopted (approxi- events may be especially ªmeaningfulº to
mately 25%). Adoptive relatives did not show individual persons and as such may particularly
increased risk. Therefore, genetic factors were dispose them to development of depression.
found to contribute to risk, but family environ- Beck and colleague's Sociotropy-Autonomy
ment was not. Scale (SAS; Beck, Epstein, & Harrison, 1983)
The family, twin, and adoption studies distinguishes sociotropic people, those for
indicate that bipolar disorder aggregates in whom affiliation with others is especially
families and is heritable. However, since the important, from autonomous people, those
concordance rates in MZ twins do not approach for whom issues of achievement and failure
100%, genetics alone is not a sufficient explana- are paramount. Hammen, Ellicott, Gitlin, and
tion for the occurrence of bipolar disorder. Jamison (1989) found that patients who
There must be non-genetic causes as well. experienced stress consistent with their SAS
Recently, genetic research has focused on the type reported significantly more depressive
identification of the means of transmission symptoms than those who did not, despite no
through studies of linkage and association. overall difference in the amount of stress
Linkage refers to the identification of a chromo- experienced.
somal region containing an ªillnessº gene, There has also been some study of the
whereas association refers to the identification possibility that different types of events may
of particular characteristics more frequent in differentially dispose people to depressive
patients than controls. Initial positive linkage versus anxiety responses. In a community
results were found for the X chromosome as well sample of 400 adult women, Brown (1993)
as chromosome 11, but these have not been found that loss provoked the onset of depres-
replicated. More promising results have been sion, danger provoked anxiety, and a combina-
found to implicate chromosomes 18 and 21 tion of the two types of stressors provoked
(Alda, 1997). comorbid anxiety and depressive disorders.
Other researchers have examined how the
6.16.4.3 Life Events association of stressful life events, maladaptive
coping responses, and depression may be
6.16.4.3.1 Life events in unipolar disorder
interrelated. Bifulco and Brown (1996) found
Since the 1960s, a voluminous literature has that, in a person's reaction to severe events, the
indicated a relationship between stressful life negative cognitive coping responses of inferred
events and increased risk for unipolar depres- denial, self-blame, and pessimism were asso-
sion. Paykel (1994) reviewed 28 studies in which ciated with increased depression risk, whereas a
more negative life events were reported by positive cognitive coping response, downplay-
depressed people prior to episode onset than ing, was not.
were reported in a similar period by people who Depressed persons may also create more
did not become depressed. Similar results have negative life events than persons not prone to
also been obtained using community samples depression. Cui and Vaillant (1997), in a
(Brown, Ahmed, Gary, & Milburn, 1995; prospective study, found that depressed men
Brown, Adler, & Bifulco, 1988), and samples experienced a greater amount of self-induced
of depressed children (Goodyer, Herbert, Tam- (dependent) negative life events after their first
plin, Secher, & Pearson, 1997). The association episode. The authors concluded that depression
between stressful life events and depression can generate these dependent negative events,
appears to be stronger for nonmelancholic and that this in turn may contribute to the
depressions; evidence for the link between chronic nature of the disorder. Similarly,
melancholic depression and precipitating life Hammen (1991) found that women with
events remains less well documented (Brown unipolar depression, but not bipolar disorder,
et al., 1994). experienced more stressful life events and more
Despite the research directed into this area, dependent events than women with chronic
the strength of the causative link between medical illness, or with no physical or psycho-
stressful life events and unipolar depression logical impairment. She theorized that these
remains difficult to gauge. Depression, be it women tended to generate stressful conditions
melancholic or nonmelancholic, is a heteroge- for themselves, particularly in the interpersonal
neous illness with many causative, perpetuating, domain, which further contributed to their
and modifying factors. Most individuals experi- ongoing cycle of depressive symptoms and
ence stressful life events and do not develop stress.
depression. Rather, life stress interacts, or is Research into the interaction of genetic
additive with, other predisposing factors to factors and life events has also indicated that
induce depression. depressed persons play a role in bringing about
their own negative stressors. Using a large order (Aronson & Shukla, 1987; Hammen &
sample of female twins, Kendler and Gitlin, 1997).
Karkowski-Shuman (1997) found that genetic Negative life events may also delay time to
liability to depression was associated with a recovery for patients who are experiencing a
greater risk for assault, serious marital pro- manic episode. Using a prospective design,
blems, divorce or breakup, job loss, serious Johnson and Miller (1997) found that those who
illness, or financial problems. The authors experienced a major stressor during a manic
suggested that genetic liability for depression episode took three times as long to achieve a full
is associated with greater life stress because recovery than those who did not experience a
genetic factors increase the likelihood that these major stressor.
individuals will place themselves in high risk A hypothesized mechanism by which stressful
environments. life events might precipitate relapse is through
Finally, some research has indicated the alteration of circadian rhythms. Models em-
importance of positive events in the recovery ploying this hypothesis have posited that
from depression. Brown et al. (1988) and Brown stressful life events disrupt normal social±
(1993) found that, in women with chronic environmental cues and physiological rhythms,
depression, life events that promise some hope including sleep and neuroendocrine function-
for a better future, termed ªfresh start events,º ing. Such disturbances in physiological pro-
were associated with recovery or improvement, cesses may precipitate manic and depressive
even if these events were threatening. episodes in vulnerable individuals (Johnson &
Miller, 1997).
6.16.4.3.2 Life events in bipolar disorder
The role of psychosocial stressors is not as 6.16.4.4 Effects of Early Environment on
well understood in the onset and course of Unipolar Disorder
bipolar disorder as it is in unipolar disorder.
This is largely because bipolar disorder is more The onset of depressive episodes is associated
heavily determined by biological factors, in with environmental circumstances that can serve
particular genetics. Even though bipolar illness as proximal causes, as described in Section
is considered largely biological in nature, the 6.16.4.3.1. The effect of such life events could be
impact of life events and psychosocial stressors to expose a genetic vulnerability, but they may
have been shown to influence recovery and also reveal a vulnerability that is in large part
relapse from affective episodes in bipolar created by events in childhood, long before the
patients (Johnson & Roberts, 1995). emergence of depressive symptoms. Early em-
Bipolar patients have been found to have a pirical efforts to isolate predisposing events in
higher number of severe stressors in the six childhood focused on parental loss, especially
months prior to the onset of a manic episode, the child's bereavement experience, as a risk
compared to nonpsychiatric controls (Kennedy, factor for later depression. More recently, the
Thompson, Stancer, Roy, & Persad, 1983), but childhood home environment of depressed
no more so than unipolar depressive or adults has been studied, primarily through their
schizophrenic patients (Johnson & Roberts, recollection of their parents' attitudes and
1995). behaviors.
Negative life events also affect relapse in With the availability of dozens of studies that
patients with bipolar disorder. Ellicott, Ham- have examined the association of parental loss
men, Gitlin, Brown, and Jamison (1990) found to later depression, it has become possible to
that patients who had the highest total life event separate the effects of different types of loss,
scores had a risk of relapse 4.5 times that of such as parental death, separation, or extended
patients who did not experience stress. Simi- absences (Parker, 1992). When examined care-
larly, Hunt, Bruce-Jones, and Silverstone (1992) fully, parental death during childhood, long
found the rate of severe negative life events was believed to predispose an individual to adult
significantly higher in the three months before depression, has not consistently been found to
relapse than in periods of time that did not be related to the disorder. Rather, parental
precede relapse. Rates were especially elevated separations, especially those that reflect or
in the month just before relapse, such that severe result in family discord, are the types of ªlossº
negative events were four times more likely in that are most clearly and consistently associated
the month prior to relapse than during other with later depression. This analysis of the effects
months. Other researchers have found that of parental loss focuses on the nature of the
patients with bipolar disorder are more suscep- parenting environment, rather than the experi-
tible to the effects of severe stressors, such as a ence of bereavement in childhood per se (Brier,
hurricane, than persons without bipolar dis- Kelsoe, Kirwin, Beller, & Wolkowitz, 1988;
Comorbidity 349
Harris, Brown, & Bifulco, 1986; Tennant, 1988). 1993), (iii) a propensity to help-seeking behavior
Researchers have thus turned their attention to (Parker et al., 1995).
the effects of parenting, with or without However, other noncausal relationships have
parental loss, as they may predispose a child not been ruled out. Genetic factors common to
to depression in adulthood. parent and child could both predispose the
The most frequently studied parenting styles parent to a style of affectionless control, and the
in this domain concern the two dimensions of (i) child to the development of depression. Alter-
parental care (ranging from caring to unaffec- natively, premorbid child characteristics may
tionate style), and (ii) parental protection (from themselves elicit pathogenic parenting. In this
appropriate encouragement of autonomy to scenario, the child's behavior is both an
overprotective style). Lack of care is hypothe- influence on parental behavior and a premorbid
sized to predispose the child to lasting self- (temperamental) characteristic that is asso-
esteem problems. Overprotection is thought to ciated with later depression.
deprive the child of education in self-reliance Recent findings from a study of adult female
and problem-solving behaviors, which may twins (Neale et al., 1994) are consistent with a
result in a sense of helplessness and hopelessness model in which poor parental style causes
when stressors are encountered in later adult life depression. Fathers' influence on their daugh-
(Perris, 1988). ters' depression status appeared to be due to
Several studies of parental style have used the their parental style, as well as to a genetic effect.
Parental Bonding Instrument (PBI; Parker, Mothers' influence appeared to be due only to
Tupling, & Brown, 1979), a retrospective their parenting style, and not genetics. Further
measure of parents' behavior during the use of behavior genetic methods (adoption
respondent's childhood. High scores on two studies, twin studies) should help to clarify the
dimensions of the PBI, low care and over- role of parental style in the development of
protection, have been associated with higher depression in later life.
depression levels in clinical (Hickie et al., 1990)
and community (Parker, Hadzi-Pavlovic,
Greenwald, & Weissman, 1995) samples. This 6.16.5 COMORBIDITY
combination of styles has been termed ªaffec- 6.16.5.1 Comorbidity with Anxiety Disorders
tionless control.º
These findings appear to be specific to There is substantial symptom overlap in
nonmelancholic depression. Research has re- depression and anxiety, including negative
vealed no association between low care or affect, restless sleep, decreased energy, irrit-
overprotection and adult melancholic depres- ability, worry, indecisiveness, and negative self-
sion (Parker & Hadzi-Pavlovic, 1992; Parker, evaluation (Alloy, Kelly, Mineka, & Clements,
Kiloh, & Hayward, 1987). The association of 1990). Both anxious and depressed individuals
parental affectionless control and later adult attach unrealistically high probabilities to
nonmelancholic depression (but not melan- negative outcomes (Beck, 1967, 1976; Beck &
cholic depression) has recently been replicated, Emery, 1985). The similarity in symptomatol-
using a non-Western sample of depressives and ogy is exemplified in the assessment instruments
controls (Sato, Sakado, Uehara, Nishioka, & used to measure the constructs of depression
Kasahara, 1997). and anxiety. For example, there is a 70% item
Research shows that the repercussions of overlap between the Hamilton Rating Scale for
parents' use of affectionless control are additive. Depression (Hamilton, 1967) and the Hamilton
That is, if both parents exhibit the affectionless Rating Scale for Anxiety (Hamilton, 1959;
control style, the risk for later depression is DiNardo & Barlow, 1990).
greater than if only one parent does so; the risk Prior to the publication of the DSM-III-R
is decreased if one parent exhibits optimal (high (APA, 1987), comorbid anxiety disorders were
care±low control) parenting style (Parker & excluded in the presence of affective disorders.
Hadzi-Pavlovic; 1992). It was presumed that affective disorders held a
The research findings cited thus far do not higher position in the classification system. This
prove that a parenting style of affectionless hierarchical classification was modified in the
control is a cause of depression. Some non- DSM III-R and DSM-IV to allow for additional
causal explanations, however, have been ruled diagnoses of anxiety disorder (i.e., panic
out. Depressed persons' reports of parental low disorder, agoraphobia, obsessive-compulsive
care and overprotection do not appear to be the disorder, generalized anxiety disorder) in the
consequence of (i) response bias in the form of a presence of a major depression.
blaming personality style (Hickie et al., 1990), When anxiety±depression comorbidity is
(ii) retrospective bias resulting from a depressed recognized, as it is in the DSM-IV, persons
mood state (Gerlsma, Das, & Emmelkamp, with a major depressive disorder are found to be
more than 10 times as likely to be diagnosed 6.16.5.2 Comorbidity with Substance Use
with an anxiety disorder than are nondepressed Disorders
persons (Boyd et al., 1984). High rates of
depression are commonly found in the course of Another type of Axis I disorder commonly
anxiety disorders, especially in individuals with found among individuals with affective dis-
panic disorder, agoraphobia, and obsessive- orders involves alcohol and substance abuse and
compulsive disorder (Akiskal, 1990). Although dependence. Among individuals with major
cases of anxiety without depression are rela- depression the lifetime prevalence rates for
tively common, cases of depression in the alcohol use and substance use disorders are 17%
absence of anxiety are quite rare (Hamilton, and 18%, respectively (Regier et al., 1990).
1983). There is some evidence that anxiety tends When these figures are used to calculate odds
to precede the onset of depression, and may be a ratios (the increased risk of developing a
response to the debilitating effects of anxiety. substance use disorder associated with depres-
Once established, anxiety disorders are not sion), individuals with major depression are 1.5
uncommonly followed by a depressive disorder, times more likely to have a comorbid alcohol
whereas depressive disorders are rarely suc- use disorder and 1.8 more likely to develop a
ceeded by an anxiety disorder. Angst, Vollrath, substance use disorder.
Merikangas, and Ernst (1990) reported that In the ECA study, bipolar disorder was found
49% of their cases with pure anxiety disorders to have the highest comorbidity with drug or
went on to develop depression, whereas only alcohol abuse of all the Axis I disorders (Regier
33% of the cases with pure depression later et al., 1990). The lifetime prevalence of alcohol-
developed an anxiety disorder. use disorders in individuals with bipolar
Merikangas (1990) reviewed family and disorder was 46%, which represents a risk ratio
genetic studies of anxiety and affective dis- of 5.3. The percentage of substance abusers
orders, which provide some evidence for a among individuals with bipolar illness was 34%,
common genetic pathway for these disorders. equivalent to an odds ratio of 8.3. Among
Although the results of this review were patients in treatment for bipolar illness, cocaine
inconsistent with respect to familial overlap, and alcohol appear to be the most common
nearly all the studies reviewed found a high agents of abuse (Fogarty et al., 1994; Sonne,
degree of comorbidity of anxiety and depression Brady, & Morton, 1994). Initially, substance
in the probands and to a lesser extent, their abuse during a manic episode may simply be
relatives. Families in which probands exhibited part of the pattern of excessive and risky
both anxiety and depressive symptoms re- behavior. However, repeated substance use
sembled depressed families more so than may cause changes in the mood-regulating
families of probands with anxiety disorders centers of the brain, which then leave the brain
alone. Likewise, families of probands with more vulnerable to recurrences of affective
anxiety or panic disorder without depression episodes (Post et al., 1986). This is similar to the
did not tend to have increased familial loading kindling process that may result from affective
for depression. In addition to finding support episodes themselves. In each case, it may be that
for the notion of pure forms of anxiety and there is a permanent degradation of brain
depression breeding true, there was also sub- regulatory processes.
stantial evidence for a mixed form of anxiety± One hypothesis regarding the increased risk
depression in which anxiety and depression in of alcohol and substance abuse among indivi-
families appear to have a common underlying duals with affective disorders is that their use
genetic contribution. More recently, in a study serves to alter negative mood states (Kantzian,
of 133 depressed and 82 controls probands, 1985). Freud (1884, cited in Goodwin &
Merikangas, Risch, and Weissman (1994) Jamison, 1990, p. 223), recognizing its mood
assessed patterns of comorbidity and cotrans- elevating properties, believed that cocaine could
mission of anxiety disorders, major depression, be used as a potent antidepressant. However,
and alcoholism. Their findings indicated that manics' increased cocaine use appears to be
anxiety, depression and alcoholism are cotrans- related to their attempts to enhance or prolong
missible in families. This relationship was euphoric mood states, rather than to ameliorate
especially strong for anxiety disorders and depressive symptoms (Weiss & Mirin, 1987).
major depression. Interestingly, their cotrans- Evidence for a common genetic pathway of
mission analyses indicated that the observed alcohol use disorders and affective disorders is
comorbidity could be explained entirely by inconclusive. Studies examining this issue have
transmitted (i.e., genetic) rather than environ- compared the prevalence of illness in relatives of
mental factors. This finding supports the patients against that found in controls. The
hypothesis that these disorders are manifesta- concept of depression spectrum disease (Wino-
tions of a shared genetic factor. kur, Cadoret, Dorzab, & Baker, 1971) came
Suicide 351
from the finding that unipolar depressed Most recently, research efforts have been
patients with alcoholic relatives differ in focused on what presenting symptoms, or
important ways from those without such psychological variables, may predict suicide in
relatives. Specifically, female relatives of pa- patients suffering from affective disorders. Un-
tients with early-onset depression were more like demographic and psychiatric history vari-
likely to be depressed, whereas male relatives ables, psychological variables are considered
were more likely to be alcoholic. Depressions ªmodifiable risk factorsº (Fawcett et al., 1990),
could be divided into pure depressive disease in that they may change as a result of treatment.
(only depressions in the family) and depression One such factor is hopelessness. Hopelessness in
spectrum disease (depressions with family the depressed patient manifests itself as a belief
histories of male alcoholism). Although many that there are no solutions to serious life
family studies have not shown an increase in problems, and that the future holds no respite
alcoholism in the relatives of depressed patients from intolerable life circumstances. In inpatients
(Merikangas & Gelernter, 1990), several adop- hospitalized with suicide ideation, hopelessness
tion studies have demonstrated an increase in has been found to be a better predictor of suicide
alcoholism in the biological relatives of de- than depression (Beck, Steer, Kovacs, & Garri-
pressed adoptees (Cadoret et al., 1996; von son, 1985); it has also been found to predict
Knorring et al., 1983; Wender et al., 1986). suicide for up to one year after its assessment
Cadoret et al. concluded that the findings of (Fawcett et al., 1990). In outpatients, hope-
adoption studies indicate the presence of a lessness has also been demonstrated as a
genetic factor for which alcoholism is a marker, significant predictor of eventual suicide (Beck,
and that a gene±environment interaction is an Brown, Berchick, Stewart, & Steer, 1990; Beck,
important etiological factor in depressive spec- Brown, Steer, Dahlsgaard, & Grisham, in press).
trum disease. Whereas the relationship between The insidious nature of hopelessness in
unipolar depression and alcoholism is mixed, it depression is illustrated in studies by Young
is clear that alcoholism does not belong in the et al. (1996) and Dahlsgaard et al. (1998). In
genetic spectrum of bipolar manic-depressive both studies, suicide was not predicted by levels
illness (Gershon, 1990). of hopelessness assessed at the beginning or
middle of treatment. In Young et al., suicide
attempts were predicted by high, stable levels of
6.16.6 SUICIDE hopelessness assessed when these patients'
depressive episodes had remitted. Similarly,
Suicide is the ninth leading cause of death in Dahlsgaard et al. found that suicide was most
the USA, accounting for more than 31 000 likely to occur in patients whose levels of
deaths in 1995 (Anderson, Kochanek, & hopelessness did not decrease during treatment.
Murphy, 1997). It is estimated that psychiatric Anxiety symptoms have been related to
illness is implicated in suicide 90% of the time suicide in work by Fawcett et al. (1990). Severe
(Goldstein, Black, Nasrallah, & Winokur, psychic anxiety, including the presence of panic
1991). Affective illness is a well-established risk attacks, and anxiety symptoms such as insom-
factor for suicide, and as such is a psychiatric nia and diminished concentration, were
disorder associated with serious risk of mortal- strongly related to completed suicide occurring
ity. Indeed, the estimated lifetime probability within one year of their assessment.
for suicide among psychiatric patients with Suicide ideation has also been proposed as an
affective disorder is 15% (Guze & Robins, obvious, and in principle modifiable, risk factor
1970). for suicide. However, communication of suicide
Several risk factors for suicide in psychiatric ideation at initiation of clinical contact has not
and community samples have been identified, been found to predict eventual suicide (Beck
including demographic variables such as male et al., 1985). More powerful predictions can be
gender, divorced or widowed civil status, made from retrospective reports of suicide
unemployment, and older age (see Hawton, ideation at its most severe point (Beck et al.,
1992, for a review). Psychiatric history vari- in press).
ables, other than affective disorder, have also Biological markers of suicide risk have
been investigated. Alcoholism (Martin, Clonin- recently been discovered. Indications of deficits
ger, Guze, & Clayton, 1985), previous suicide in the neurotransmitter serotonin have been
attempts (Borg & Stahl, 1982), past psychiatric observed in depressed suicide attempters (Les-
hospitalizations (Pokorny, 1983), and prema- ter, 1995). This has been found to be especially
ture termination or unfavorable outcome of true in those with more serious attempts (Mann
therapy (Dahlsgaard, Beck, & Brown, 1998; & Malone, 1997), and those who went on to
Goldstein et al., 1991) are associated with complete suicide within 1 year (NordstroÈm et al.,
increased suicide risk. 1994).
6.16.7 THEORIES AND TREATMENTS OF cells, that have a more direct effect on mood and
UNIPOLAR DISORDER other symptoms of depression.
The brain structure most consistently im-
6.16.7.1 Biological Theories and Treatments of plicated in mood disorders is the hypothalamus.
Unipolar Disorder The effect of hypothalamic activity on other
biologic systems has thus been of great interest
There is no one biological theory of unipolar (Musselman & Nemeroff, 1996). Hypothalamic
depression. Instead, the biological characteriza- activity affects the pituitary gland, which in turn
tion of the state of depression is quite complex affects activity in the thyroid and adrenal
and incomplete, and it involves many biological glands. Abnormalities of thyroid activity have
systems and levels of analysis. One can begin at been found in depressed patients, and medica-
the level of the neurotransmitter, which is where tion treatments that include the use of synthetic
modern theories of the biology of depression thyroid hormone have been found to be
have focused. Abnormalities in hormonal effective. The adrenal hormone cortisol, com-
functioning, as well as structural abnormalities monly considered a stress hormone, tends to be
in the brain, have also been examined. elevated in depressed people. Moreover, the
In its simplest form, the amine theory of cortisol regulation system, as assessed by the
depression, originally proposed by Schildkraut dexamethasone suppression test (DST), is
(1965) and Glassman (1969), is that depression impaired in many depressed patients.
is caused by decreases in brain levels of the Individual tests of thyroid and adrenal
neurotransmitter norepinephrine (NE) or ser- malfunction have thus far not been sensitive
otonin (5-HT), both of which belong to a class and specific enough to guide diagnosis and
of neurotransmitters called amines. Evidence treatment. Not surprisingly, the combined
for this theory came in part from observing results of several tests yield better results. For
neuronal effects of drugs that reduce depressive example, when Banki, Arato, Papp, Rihmer,
symptoms. The tricyclic antidepressants (TCAs) and Kovacs (1986) used four neuroendocrine
inhibit the reuptake of NE and 5-HT into the tests, they found that 11 of 21 (52%) depressed
presynaptic terminal. The inhibition of reuptake patients obtained abnormal results on at least
is presumed to make more amines available for three of them. Only 3 of 44 (7%) of non-
neurotransmission, which in turn is presumed to depressed psychiatric patients, and 0 of 15
return the amine systems to normal levels of nonpsychiatric patients, achieved a similar
functioning. Normal amine functioning, in turn, result.
translates into normal mood functioning (but In addition to neurotransmitter and neuroen-
see Richelson [1991] who argues that the amine docrine abnormalities, abnormalities of brain
effects explain the side effects, not the ther- structure have been identified (Soares & Mann,
apeutic actions of the drugs). 1997). Although global brain atrophy has not
The amine story cannot be as simple as the been found, the basal ganglia, the cerebellum,
version described above. The effects of TCAs and the frontal lobe appear to be reduced in size
on the inhibition of reuptake are nearly in unipolar depression. Each of these areas has
immediate, yet these drugs take more than a connections to brain structures known to
week to exert their therapeutic effect. A partial participate in the regulation of mood. For
explanation of this delay involves a regulatory example, the cerebellum projects to norepi-
system called the a2 autoreceptor. This receptor, nephrine cell groups in the limbic system.
which sits on the presynaptic membrane, Therefore, cerebellar atrophy is suspected to
regulates the release of NE into the synapse play a role in the inability of the limbic system to
by detecting how much NE is in the synapse regulate processes that are responsible for
already, and inhibiting the further release of normal mood functioning.
NE. After days or weeks of treatment, during The major biological treatment modalities for
which time the a2 autoreceptor is fighting to unipolar depression are medication and electro-
maintain the pretreatment synaptic level of NE, convulsive therapy. Antidepressant medications
it downregulates. This means that it reduces its fall into three classes: tricyclic antidepressants,
activity, and thereby allows more NE to be selective serotonin reuptake inhibitors, and
released into the synapse. monoamine oxidase inhibitors.
An even more sophisticated analysis of the Treatment of depression with antidepressants
role of amines in depression has recently been is effective in cases of moderate to severe
articulated by Heninger, Delgado, and Charney depression. The utility of medicines for milder
(1996), based on findings from biological forms of depression, however, is in doubt. Elkin
challenge tests. Heninger et al. conclude that et al. (1989) found no advantage of the
the role of amines is to regulate other biological antidepressant medication imipramine over a
mechanisms, likely to be found within nerve placebo condition for patients who, at intake,
Theories and Treatments of Unipolar Disorder 353
scored below 20 on the Hamilton rating scale for or SSRIs (Quitkin et al., 1993). The category
depression (Hamilton, 1967). The advantage of atypical depression includes nonmelancholic
imipramine over placebo was clear, however, depression, or depression with anxiety, rejection
among the more severely depressed patients (see sensitivity, chronic pain, or the reversed vege-
also Paykel, Hollyman, Freeling, & Sedgwick, tative symptoms of appetite increase and
1988; Stewart et al., 1983). Typical symptom hypersomnia (Lam & Stewart, 1996). The
clusters that predict a favorable response to medicines phenelzine (Nardil) and tranylcypro-
antidepressant medications are: decreased ap- mine (Parnate) belong to the class of MAOIs.
petite, insomnia, acute onset, a family history of Whereas the TCAs and SSRIs are presumed
depression, and a personal or family history of to alter neurotransmission functioning by
positive response to antidepressant medications inhibiting reuptake of amines into the presy-
or electroconvulsive therapy (APA, 1980). naptic cleft, MAOIs act through the inhibition
The efficacy of TCAs is demonstrated most of monoamine oxidase (MAO). MAO is an
thoroughly by research on imipramine. The enzyme that breaks down norepinephrine,
oldest and most widely prescribed TCA, its either in the synapse or in the presynaptic
most common brand name in the USA is terminal (McNeal & Cimbolic, 1986).
Tofranil. Imipramine has been compared to Frequently reported side effects of MAOIs
placebo in nearly 50 double-blind studies. The include headaches, dry mouth, insomnia, con-
combined findings reveal a 65% improvement stipation, sedation, blurred vision, and nausea.
rate with imipramine, compared to 30% with Of particular interest is the potential for
placebo (Goodwin, 1992). Other commonly unpleasant, or even fatal, interactions of MAOIs
used TCAs are amitriptyline (Elavil) and with foods containing high levels of tyramine.
doxepin (Sinequan). While taking MAOIs, one must avoid aged
As with all medicines, side effects can occur cheeses, red wines, soy sauce, smoked fish, and
with TCAs. Common cardiovascular side other foods containing tyramine (Davidson,
effects include tachycardia (increased heart 1992).
rate) and postural hypotension (a sudden drop Electroconvulsive therapy (ECT) is generally
in blood pressure when arising from a bed or a considered a last resort treatment, to be used
chair). Neurological side effects are fairly with patients whose depression severity requires
common, especially sedation. Due to the hospitalization, or those who are not adequately
neurological and cardiovascular toxicity of responsive to antidepressant medications (Fink,
TCAs, the use of these medicines in suicide 1992). There are cases, however, in which ECT
attempts is a serious risk. For this reason, is considered a primary treatment, such as when
special caution is exercised when these drugs are a rapid treatment response is needed, when risks
used to treat suicidally depressed patients. of medications are greater than those of ECT,
Administration of selective serotonin reup- when a poor history of drug response and/or a
take inhibitors (SSRIs) is indicated in the same positive history of response to ECT exists, or
cases of depression that indicate administration when the patient prefers ECT to other treat-
of TCAsÐmoderate to severe depression of a ments. ECT is especially effective when depres-
fairly typical character. These newer antide- sion is accompanied by psychosis or marked
pressants are often preferred to TCAs because psychomotor retardation and depressive stupor
they exhibit comparable effectiveness but have (Enns & Reiss, 1992; Fink, 1992).
reduced side-effects and a much reduced over- ECT has been shown to be more effective
dose potential relative to TCAs (see Greenberg, than sham ECT in double-blind controlled
Bornstein, Zborowski, Fisher, & Greenberg's studies in the treatment of major depression
[1994] meta-analysis of fluoxetine [Prozac] (Gregory, Shawcross & Gill, 1985). Further,
outcome). Besides fluoxetine, other commonly ECT has been shown to be more effective than
prescribed SSRIs are paroxetine (Paxil) and moderate doses of TCAs (Ghangadhar, Kapur,
sertraline (Zoloft). Common side effects of the & Kalyanasundaram, 1982).
SSRIs tend to be gastrointestinal or sexual, Although the mechanisms through which
including nausea, diarrhea, and sexual dysfunc- ECT achieves its antidepressant effects are
tion. Decreased appetite, nervousness, and poorly understood, it is known that the
tremor are also reported (Guze & Gitlin, induction of a grand mal seizure is essential
1994). Because the cardiac and neurological for the success of ECT. One possibility is that
side effects are less than those of TCAs, SSRIs the release of norepinephrine and dopamine
are associated with a much lower risk for use in during the seizure leads to overall improvement
lethal overdose. in the functioning of amine systems (Sackeim,
Monoamine oxidase inhibitors (MAOIs) are 1989).
generally indicated in cases of atypical depres- Patients with major depression generally
sion that would not respond adequately to TCAs receive seven to nine treatments, three times
per week, with improvement generally evident A research literature relevant to the question
after four or five treatments. The most common of cognitive vulnerability concerns the reformu-
side effects associated with ECT as it is currently lated learned helplessness, or hopelessness,
implemented are cognitive impairment and model of depression (Abramson, Metalsky, &
memory loss. Although memory loss is gen- Alloy, 1989). According to this model, vulner-
erally limited to the periods around the time of ability to depression is in the form of char-
the treatments, some patients report loss of acteristic ways of explaining events, especially
memory of events that occurred before ECT, or bad ones. This pattern is referred to as a
even before the depressive episode (Fink, 1992). depressogenic inferential style. The person with
this style has a tendency to attribute bad events
to causes that are internal (due to, or inherent in,
6.16.7.2 Cognitive Theories and Treatments of the person), stable (likely to persist over time),
Unipolar Disorder and global (applicable to many domains of the
person's life). Given this style, the occurrence of
The cognitive theory has been the most a bad event is especially likely to lead to specific
influential psychological theory of depression depressogenic inferences, which will then lead to
since the 1970s. Its heuristic value as a way of negative expectations, or a state of hopelessness.
describing the experience and behavior of the The state of hopelessness then generates the
depressed person has been widely accepted. Its other symptoms of depression.
value as an etiological theory and as a basis for Research findings have yielded equivocal
treatment, especially in severe forms of depres- support for this model (Barnett & Gotlib,
sion, has been more controversial. 1988). Abramson, Alloy, and Metalsky (1988)
Beck's (1967) early writings about depression argue, however, that many investigators have
came against the backdrop of the influence of used research designs that are not appropriate
psychoanalytic understandings of depressive to test the set of hypotheses embedded in the
phenomena. He argued that cognitive phenom- hopelessness model. A large study designed
ena that are available to introspection are at the specifically to test the hopelessness model is near
core of, and can explain the presence of, the other completion; its findings strongly support the
features of depression. Depressive mood is said hypothesis that cognitive vulnerability interacts
to be the natural consequence of negative beliefs with stressful life events to produce the beliefs,
about the self, the future, and the world (the and then the symptoms, associated with
negative cognitive triad). Likewise, behavioral depression (Abramson, Alloy, Hogan, & White-
disturbances, such as response initiation deficits, house, 1997; Alloy, Abramson, Murray, White-
are seen as resulting from a belief in the futility house, & Hogan, 1997).
of action. For example, whereas in a psycho- A critical aspect of any psychological model
analytic formulation of depression the failure of of depression is its ability to delineate distal
a depressed person to keep an appointment for a causes. If there are persons who possess a
job interview might be interpreted as an instance thinking style that makes them vulnerable to
of unconsciously motivated self-punishment, depression in the face of negative life events, it is
the cognitive model would focus on the negative likely that both genetic (Schulman, Keefe, &
expectations of the depressed person (e.g., ªI'll Seligman, 1993) and environmental factors play
make a fool of myselfº; ªI'll never get that job a role in the development of that style. The
anywayº). Findings from literally hundreds of recent findings reported by Garber and Flynn
studies (Haaga, Dyck, & Ernst, 1991) have (in press) suggest that a relative absence of
supported this characterization of the thinking maternal acceptance and the presence of
of depressed people. maternal psychological control contribute to
What makes a person vulnerable to this kind the development of thinking styles character-
of thinking? Is depressive thinking, like sleep istic of persons at risk for depression. These
disturbance, merely a symptom of depression findings accord with the observation that
that arises during the episode, or are there depressed adults report having experienced a
premorbid cognitive phenomena that act as parental style of affectionless control (Parker,
vulnerabilities? Beck has argued that depressed 1992). Garber and Flynn also found that
people possess ªdepressive schemasº even whereas correlations between children's and
before the first onset of a depressive episode. parent's thinking styles were low, mothers'
However, because these schemas are latent, they explanations of their children's behavior were
are difficult to detect. Miranda and Persons related to their children's own explanations
(1988) have proposed that latent schemas can be regarding their behavior. Hence, only on
detected, in principle, by assessments conducted explanations of child-focused events, and not
when the vulnerable person is in a sad mood general thinking style, were mothers and
(Hedlund & Rude, 1995). children similar.
Beck's cognitive therapy for depression The kinds of negative thoughts most fre-
(Beck, Rush, Shaw, & Emery, 1979; DeRubeis quently reported by depressed patients involve
& Beck, 1988) has for the last 20 years beliefs about the self (e.g., ªI'm worthlessº), the
epitomized modern, brief, semistructured forms future (ªI'll never get another jobº), or the world
of psychosocial interventions for serious mental (ªPeople are uncaringº), that is, Beck's (1967)
disorders. Two factors have been especially negative cognitive triad. Hollon and Kriss (1984)
important in the popularity of this form of classify automatic thoughts into (i) attributions,
therapy for depression. First, beginning in 1977 which are explanations about past events (e.g.,
(Rush, Beck, Kovacs, & Hollon, 1977), there ªThe breakup with my girlfriend was all my
has been a series of impressive demonstrations faultº); (ii) ascriptions, which are descriptions of
of the efficacy of cognitive therapy. Second, present states (e.g., ªI'm unlovableº); and (iii)
Beck et al.'s (1979) description of cognitive expectations, which are predictions about the
therapy, as detailed in their classic therapy future (e.g., ªI'll never marryº). However one
manual, has been admired for its clarity, detail, classifies these thoughts, the assumption is that
and thoroughness. Professionals who find they are observable, either as (complete or
descriptions of psychoanalytic methods too partial) sentences, or as visual images (e.g., an
unstructured, and behavior therapy too restric- image of oneself, old and alone, with no loved
tive, find a middle ground in cognitive therapy. ones present). It is further assumed that many of
Similarly, it has captured a segment of the the thoughts are incorrect or invalid, or that the
educated public, who find that the ideas implications depressed patients derive from the
embedded in cognitive therapy (Burns, 1980) thoughts are exaggerated toward the negative
are both practical and consistent with common (e.g., ªSince my relationship is over, I will never
sense. find another good relationshipº).
The beginning assumption in cognitive For many patients, once the thoughts are
therapy for depression is that depressed patients noticed, they can be seen as exaggerations or
frequently engage in ill-considered negative distortions. Therapy is facilitated further when
thinking that, when held up to scrutiny, will patients write the thoughts on paper. The
be found in error. Although there has been an concreteness of thoughts written down lends
interest by some writers, beginning with Freud them to serious, dispassionate reconsideration.
(1917/1957; Alloy & Abramson, 1982, 1988), in The next element of therapy, then, entails
the idea that depressed people see the world teaching the patient the most effective means of
more clearly than nondepressed people, there is reconsidering their thoughts. Four classes of
no good evidence for this view (Ackermann & questions address most thoughts reported in
DeRubeis, 1991). Moreover, this depressive therapy. The first question is, ªWhat is the
realism hypothesis runs counter to common evidence that the thought is true, or not true?º
sense; the most interesting version of this The first half of the question is aimed at getting
hypothesis implies that the most severely the patient to explicate the basis for a belief; the
depressed person will also be the wisest, clearest second half will challenge the belief, if there is
thinker. This proposition is, prima facie, relevant evidence to counter it. The second
incorrect if not foolish. question is, ªAre there alternative explanations
The therapist's first task in cognitive therapy, that have not been considered?º This question is
then, is to teach the patient to attend to their especially relevant when patients assign self-
thoughts, some of which will be distorted. These blame inappropriately or excessively. The third
thoughts may be quite prominent in the questionÐªWhat are the implications if the
patient's attentional focus, even before the belief is true?ºÐis directed at the tendency for
beginning of therapy, in which case the patient depressed patients to imagine exaggerated
merely needs to learn to remember them or, consequences of real failures or shortcomings.
better yet, write them down for further The fourth questionÐªWhat can I do?ºÐ
consideration. It may take extensive instruction follows from the others. Once a problem has
and practice before the patient learns to capture been identified, relatively free of distortion and
the stream of thoughts that accompanies almost exaggeration, a plan of action can be developed
any experience. Of course, the greatest efforts rationally.
are directed at observing thoughts that occur Cognitive therapy has also been called
before, or during, an unpleasant emotional cognitive behavior therapy, in part because
state, such as sadness or despair. The term the fourth question focuses on action. More-
ªautomatic thoughtsº has been used to refer to over, especially early in treatment, behavioral
the spontaneous nature of many of these techniques are employed to counter the failure
thoughts. Their automatic, effortless, tacit, of depressed people to initiate action that could
and habitual nature can make them especially lead to pleasure or a sense of accomplishment.
difficult to notice. Cognitive therapists help patients break tasks
into their smaller components, and to plan to did not outperform placebo significantly, and
engage in activities they have been avoiding. At some analyses of the outcome data indicated
each point, the cognitive therapist is interested that imipramine was more effective than
both in increasing the patient's engagement in cognitive therapy for the more severely de-
the world, and in discovering the distorted pressed patients (Elkin, Gibbons, Shea, &
beliefs that have prevented them from doing so Sotsky, 1995). This pattern of findings from
during the depression. the TDCRP led the APA (1993) to publish
Cognitive therapy is a skills-based treatment treatment guidelines that questioned the effec-
(Barber & DeRubeis, 1989). The hope is that tiveness of cognitive therapy for depression,
patients will not only benefit from the thera- especially in its more severe forms. Recently,
pists' interventions, but that they will learn how DeRubeis, Gelfand, Tang, and Simons (1998)
to apply the interventions to themselves. But have reanalyzed data from only the more
cognitive therapy, especially as recent writers severely depressed patients from the Rush
have described it (Persons, 1989), is also a kind et al. (1977), Murphy et al (1984), Hollon
of insight therapy. Therapists help patients to et al. (1992), and TDCRP studies. Considering
discover idiosyncratic patterns of belief, or the patients in all four studies combined,
schemas, that they apply across a wide range of cognitive therapy was at least as effective as
situations. Therapy can then focus on the medications during the acute treatment phase.
developmental origin of the schemas. Many Thus, treatment guidelines that focus only on
modern cognitive therapists believe that therapy the failure of cognitive therapy in the TDCRP
is unsuccessful if it does not include the appear to underestimate the short-term benefits
identification of schemas and their origins. of cognitive therapy for severely depressed
However, all of the outcome research has been outpatients. Further research on cognitive
conducted with therapists who have not placed therapy and pharmacotherapy for severely
great emphasis on the schema aspect of depressed outpatients is currently being con-
cognitive therapy. It remains to be seen whether ducted. This study will also examine the putative
it is the acquisition of skills, or the under- relapse prevention benefits of cognitive therapy.
standing of themes and origins, that is most The specificity of cognitive therapy for
critical to the success of cognitive therapy depression, once inferred primarily from its
(Barber & DeRubeis, 1989). equivalence to pharmacotherapy (Dobson,
In 1977, Rush, Beck, Kovacs, and Hollon 1989), is now being questioned. Not only have
published the first findings indicating that a there not been many comparisons of cognitive
psychosocial treatment could intervene in a therapy to other psychosocial interventions,
depressive syndrome as quickly and effectively there has also been virtually no research
as a pharmacological treatment. In fact, due in comparing cognitive therapy to control condi-
part to a design artifact, cognitive therapy was tions. In the TDCRP, cognitive therapy did not
said to be significantly more effective than surpass the interpersonal therapy condition or
imipramine pharmacotherapy in that study. the placebo condition. Indeed, there were some
Findings from subsequent studies (Hollon et al., indications of the superiority of interpersonal
1992; Murphy, Simons, Wetzel, & Lustman, therapy in that study, especially in the more
1984) converged on the conclusion that cogni- severe sample. A recent study by Jacobson et al.
tive therapy is as effective and as fast-acting as (1996) suggested that behavior therapy is as
antidepressant medications as an acute treat- effective as cognitive therapy for depression.
ment of depressed outpatients. Moreover, Jacobson is following up this finding in a larger
follow-up results from these studies, especially design that will include a pharmacotherapy
the Evans et al. (1992) follow-up of the Hollon group, as well as a placebo control. Indications
et al. study, suggested that short-term cognitive of the potency of cognitive therapy gleaned
therapy prevents relapse relative to equally from the studies summarized in DeRubeis et al.
short-term pharmacotherapy (Hollon, Shelton, (1998) cannot be ignored, but the set of
& Loosen, 1991). investigations currently underway will refine
These conclusions were widely accepted until the answers to questions about the short- and
the publication of findings from the large, multi- long-term benefits of cognitive therapy for
center Treatment of Depression Collaborative depression.
Research Program (TDCRP; Elkin et al., 1989).
Whereas none of the previously mentioned
studies included a control group in their design, 6.16.7.3 Behavioral Theories and Treatments of
the TDCRP included a pill-placebo condition, Unipolar Disorder
as well as cognitive therapy, imipramine
pharmacotherapy, and interpersonal therapy Lewinsohn (1974) has written most exten-
conditions. In the TDCRP, cognitive therapy sively about the role of behavior theory and
behavior therapy in depression. In the beha- tolerance skills, and to encourage the use of
vioral view, depression is seen as the result of a these skills, especially during times of suicide
low rate of positive reinforcement. The de- ideation. In a randomized comparison with a
pressed person is unable to obtain gratification, treatment as usual condition, DBT patients
either because there are very few reinforcing exhibited better overall adjustment, as well as
stimuli in their environment, or because of a anger control, at treatment termination (Line-
deficit in skills, especially social skills. De- han, Tutek, Heard, & Armstrong, 1994).
pressed mood and behavior become part of a Because the chronically suicidal borderline
vicious cycle, in which depressive behavior, patient is considered especially difficult to treat,
because others find it unpleasant, is especially these preliminary indications of the effective-
unlikely to lead to positive reinforcement from ness of DBT have been greeted with enthusiasm
others. According to this view, there are two by practitioners and treatment researchers.
promising points of entry in therapy for
depression: acquisition of skills, especially
social skills; and enrichment of the environ- 6.16.7.4 Psychodynamic Theories and
ment, by identifying, planning, and engaging in Treatments of Unipolar Disorder
potentially reinforcing activities.
In two studies behavior therapy has out- The earliest modern psychological theory of
performed control conditions. Shaw (1977) depression was described by Freud (1917/1957)
found that patients in his behavior therapy in his classic paper, Mourning and melancholia.
group improved more than those in a wait-list Central to Freud's theory was the proposition
condition. (However, they improved less than that loss precedes all episodes of melancholia, as
those in his cognitive therapy group.) McLean it does in all instances of mourning. Freud
and Hakstian (1979) conducted a large study in delineated the similarities between mourning
which they compared behavior therapy to and melancholia, such as sad mood and
psychotherapy, relaxation therapy, and ami- decreased interest in people and activities, all
triptyline pharmacotherapy. Significantly of which could be accounted for by loss.
greater symptom change was observed in their Freud then focused on the unique, defining
behavior therapy condition than in each of the features of melancholia, most importantly self-
other three conditions. reproach, and suicidal thoughts and actions. He
In a recent study of 150 outpatients by posited that desires to harm or punish oneself are
Jacobson et al. (1996), behavior therapy pro- best understood as deriving from a wish to harm
duced as much change in depressive symptoms the lost object, or some aspect of it. So, for
as either of two cognitive therapy conditions. example, the depressed person who fails to show
This result was not due to poor outcome in the up for a job interview could be seen as manifestly
cognitive therapy conditionsÐrecovery rates punishing or harming him- or herself, but the
and mean end-of-treatment scores on standard unconscious motive for this may be a wish to
measures were impressive in all three groups. punish his or her deceased father. Necessary for
Jacobson and colleagues are following up these the development of this wish to punish another
findings with an even larger scale study that will object is a history of ambivalent love for that
pit behavior therapy and cognitive therapy object. Under conditions of ambivalent love,
against each other, as well as against medication when the object is lost and is incorporated into
therapy and a placebo control condition. the self (ego), both the loved and hated elements
Nezu (1986) has described a behavioral of the object become part of the ego. From that
program he calls problem-solving therapy, point on, when a wish to retaliate against or
which assumes that depressed persons have lost harm the lost object occurs unconsciously, it is
(or never possessed) the skills necessary to solve manifest as a wish to harm the self, through the
life problems. Problem solving therapy has defense of retroflection, whereby anger towards
performed well in two controlled comparisons another is transformed into anger turned
with depressed outpatients (Nezu 1986; Nezu & inward. Many mental health professionals
Perri, 1989). Problem solving approaches that believe that retroflected anger is an important
are directed at the suicidal behavior of basis for depressive symptoms, especially those
depressed people also appear to be promising. that are self-defeating. Belief in the phenomenon
Linehan (1993) has developed a cognitive of retroflected anger has formed the basis for the
behavioral approach to the treatment of popularity of efforts to help depressed people
chronically suicidal patients with borderline release their anger. Nonetheless, there have been
personality disorder. Termed dialectical beha- no systematic investigations of the effectiveness
vior therapy (DBT), the goals of this treatment of Freudian psychoanalysis for depression, or of
are to remediate deficits in interpersonal, any treatment based on the anger-turned-inward
emotion regulation, self-regulation, and distress hypothesis of depression.
Whereas the psychoanalytic theory of depres- well as a version of cognitive behavioral therapy
sion focuses on a pathological motivational in a large sample of depressed outpatients.
system, and cognitive theory focuses on pathol- However, there were also some indications that
ogy of belief, interpersonal±psychodynamic PI was not as effective as cognitive behavior
theory of depression focuses on the pathological therapy.
relation of the person to their interpersonal Thus, although there has been little effort to
environment. The interpersonal theory of test Freud's psychoanalytic treatment for
depression is a specific application of a general depression, active research programs exist that
interpersonal theory of psychopathology, aim to evaluate more structured versions of
whose best known advocates are Meyer therapies that derive from psychoanalytic
(1957) and Sullivan (1953). In the interpersonal thought. This is part of a modern trend for
theory of depression (Klerman, Weissman psychodynamic thinking to be instantiated in
Rounsaville, & Chevron, 1984), four types of short-term, focused interventions for specific
interpersonal pathology are elaborated. A given disorders (Barber & Crits-Christoph, 1995).
depressed person is expected to exhibit one or
more of these. Abnormal grief refers to either a
prolonged grief reaction, or a distorted grief 6.16.8 THEORIES AND TREATMENTS OF
reaction in which normal grieving processes do BIPOLAR DISORDER
not occur. Interpersonal role disputes involve 6.16.8.1 Biological Theories and Treatments of
relationships that are one-sided or nonrecipro- Bipolar Disorder
cal. Abnormal role transitions refer to a
person's inability to cope with life changes. Neurochemical theories of mania invoke the
Finally, interpersonal deficits are seen in people same neurotransmitter systems as are implicated
who have had a poverty of social relations in unipolar depression. In Schildkraut's (1965)
throughout their lives. classic formulation, whereas depressive disor-
The interpersonal theory of depression is ders were associated with a functional deficit of
associated specifically with a brief, structured catecholamines (particularly norepinephrine),
psychosocial intervention for depression, manias were said to involve a functional excess of
termed interpersonal psychotherapy (IPT; Kler- catecholamines. The major metabolite of the
man et al., 1984). The benefits of IPT in catecholamine norepinephrine (NE), namely
depressed outpatients were first examined by 3-methoxy-4-hydroxyphenylglycol (MHPG),
DiMascio et al. (1979). IPT achieved symptom has been shown to be elevated in bipolar patients
reduction equivalent to that observed in a when they were manic, compared with levels
medication condition, although the medications when depressed (Halaris, 1978). Similarly,
achieved their effects more rapidly. In compar- bipolar patients, when manic, demonstrate
ison to a minimal contact control condition, IPT significantly higher plasma NE and epinephrine
effects were superior. levels than when they are depressed or euthymic
Interpersonal therapy also performed well in (Maj, Ariano, Arena, & Kemali, 1984). Swann
the TDCRP (Elkin et al., 1989). At post- et al. (1987) reported that MHPG and NE levels
treatment, the depressive symptoms of IPT in cerebral spinal fluid were significantly higher
patients reached levels almost as low as those in manic patients than in either depressed or
achieved in the medication condition, and control subjects.
slightly lower than those of patients treated The permissive hypothesis of serotonin
with cognitive therapy. (Neither difference was (Prange, Wilson, Lynn, Alltop, & Stikeleather,
significant.) When the authors examined data 1974) posits that a deficit in serotonergic
from the patients who were more severely transmission permits the expression of manic
depressed prior to treatment, there were some depressive illness, although a deficit is not
indications that IPT was superior to placebo. sufficient to cause it. According to this theory,
Another psychodynamically based interven- both the manic and depressive phases of bipolar
tion, psychodynamic interpersonal psychother- illness are characterized by low serotonin
apy (PI; Shapiro et al., 1994), has been examined (5-HT) function, but differ in terms of NE
as a treatment for depression. The main activity (high in mania, low in depression).
difference between PI and IPT appears to be Serotonin systems inhibit a variety of functions
that PI focuses more on the relationship between served by other neurotransmitters. Defective
the patient and the therapist, using it as a vehicle (low) serotonergic function, and the corre-
for understanding the patient's interpersonal sponding lack of inhibition of other neuro-
relationships more generally. In psychodynamic transmitter systems, especially NE and
terms, PI attends to the transference relationship dopamine (DA), permits wide variations in
between patient and therapist. Shapiro et al. affective symptomatology from depression to
found that on some measures, PI performed as mania.
Theories and Treatments of Bipolar Disorder 359
Goodwin and Sack (1974) analyzed the from patient to patient, and can vary within the
effects of drugs on the DA or NE system in same patient; patients in an active manic
relation to the relative efficacy of the drugs episode typically require higher dosages than
against different symptoms of mania. Their they do to remain in a normal mood. Lithium is
analysis led them to suggest that DA abnorm- very effective in the treatment of acute mania;
alities are primarily involved in the hyperactiv- Goodwin and Zis (1979) reported a 78% overall
ity and psychosis associated with the more response rate in a review of four double-blind,
severe stages of mania, whereas excesses in NE placebo-controlled studies. In addition to acute
underlie the euphoria and grandiosity more treatment, lithium is also effective in reducing
characteristic of less severe forms of mania, or future manic and depressive episodes in bipolar
hypomania. patients when used prophylactically (Prien,
Janowsky, El-Yousef, Davis, and Sekerke Caffey, & Klett 1974; see Goodwin & Jamison,
(1972) postulated that an increased ratio of 1990, for a review).
cholinergic to adrenergic activity underlies The anticonvulsants carbamazepine and
depression, and that the reverse is true in valproate are also commonly used. They are
mania. In this view, mania results when used alone or in conjunction with lithium, and
increases in NE (an adrenergic transmitter) are commonly used in the treatment of lithium
effect an imbalance relative to cholinergic (i.e., nonresponders. In a recent meta-analysis,
acetylcholine) activity. This hypothesis derives Emilien, Maloteaux, Seghers, and Charles
from the fact that antidepressant medications (1996) found the therapeutic efficacies of
have substantial anticholinergic properties. carbamazepine and valproate to be comparable
Moreover, drugs that stimulate acetylcholine to lithium in the treatment of acute mania. In
decrease manic symptoms in manic patients, StroÈmgren and Boller's (1985) review of 15
and they increase depressive symptoms in studies, 55% of patients were reported to have
depressed patients. These same drugs also had a marked or moderate response to carba-
induce depressions in nondepressed subjects. mazepine. Carbamazepine and valproate have
Clinical and pharmacological data suggest both been shown to have prophylactic effects as
that g-aminobutyric acid (GABA) metabolism well (Coxhead, Silverstone, & Cookson, 1992;
is altered in bipolar disorder. GABA has McElroy, Keck, Pope, & Hudson, 1992).
inhibitory input into other neurotransmitter
systems such as NE and DA, and regulates
many central nervous system functions, includ- 6.16.8.2 Psychosocial Theories and Treatments
ing seizure threshold. The role of GABA in of Bipolar Disorder
convulsive disorders has been extensively stu-
died, and antiepileptic drugs appear to act Psychosocial theories and treatments of
directly or indirectly on GABA. The antiepi- bipolar disorder follow from an understanding
leptic agents valproic acid and carbamazepine that, although the disorder has predominantly
were serendipitously noted to have a mood- genetic causes, its course is responsive to
stabilizing effect, decreasing the intensity and environmental stressors (Johnson & Miller,
frequency of both manic and depressive phases 1997). As adjuncts to medication therapy,
of bipolar disorder. In addition to valproic acid, psychosocial treatments aim to enhance med-
other antimanic agents, such as lithium and ication compliance, and to increase resilience to
carbamazepine, appear to stabilize mood by stress. Miklowitz and Goldstein (1990) have
increasing GABA-ergic transmission, leading to developed family-focused treatment (FFT) for
the hypothesis that GABA deficiency plays a bipolar disorder. The goal of FFT is to reduce
role in mania (Bernasconi, 1982). family conflict, which is believed to precipitate
The behavior of the manic person, especially relapse. In the initial phase of FFT, patients and
when agitated or violent, can be so extreme as to their families are educated about the symptoms
warrant immediate, aggressive therapeutic ac- of the disorder, the importance of medication
tion. Medical management is almost always the compliance, and the strategies to employ if the
first line treatment for a manic episode. patient begins to relapse. In the later stages of
Lithium is the oldest of the modern antimanic FFT, the psychoeducational focus is on im-
agents. Lithium's antimanic properties were proving family interactionÐall family members
first discovered by John Cade in 1949, but it was learn communication and problem-solving
not used in the USA until the 1960s. Since then, skills (Miklowitz, Frank, & George, 1996).
it has remained the medication of choice for A similar psychoeducational approach is
mania. Plasma lithium levels must be monitored found in the treatment known as interpersonal
to maintain a therapeutic level, and to avoid and social rhythm therapy (IPSRT; Frank et al,
toxic effects. The plasma level of lithium 1997). IPSRT methods were developed in
required to produce clinical response varies recognition that irregular sleep and circadian
patterns can be detrimental to the bipolar paranoid beliefs, along with dismissal of
patient. Patients are shown that interpersonal disconfirming evidence. These tendencies, as
stressors and social role transitions may upset well as the patient's desire to maintain a manic
daily routines, which in turn may disrupt or hypomanic state, are addressed with stan-
circadian regularity and lead to relapse. During dard cognitive therapy methods.
the course of therapy, patients are taught how to In cognitive therapy, behavioral interventions
negotiate interpersonal dilemmas and role are used to limit self-stimulating behaviors.
transitions, and they are coached in how to Activities that have a high potential for
regularize and maintain stable daily routines, dangerous consequences or which might serve
even when they encounter stressors in their to exacerbate the episode are identified early on,
environments. and the therapist helps to plan strategies for
Both FFT and IPSRT therapies are currently avoiding or limiting these activities. These
under investigation in randomized clinical include, as in IPSRT, maintaining a regular
studies. Preliminary results show that both sleep schedule, as well as limiting spending,
treatments produce high patient retention rates alcohol and drug use, and other risky behavior.
through the first year of treatment (Miklowitz Problem-solving skills are employed to address
et al., 1996). In addition, IPSRT patients have stressful life events that might precipitate
demonstrated increasing stability of daily relapse, and to address difficulties arising in
routines over the course of treatment (Frank the aftermath of an affective episode, such as the
et al., 1997). financial difficulties that result from excessive
Newman and Beck (1992) have described a gambling or the loss of employment. Thus far,
cognitive model in which mania is characterized there have been no controlled clinical studies of
by a positive cognitive triad: the self is seen as cognitive therapy of bipolar disorder.
highly valued and powerful, experience is
viewed as overly positive, and the future is
replete with opportunity. The distortions asso- 6.16.9 SUMMARY AND FUTURE
ciated with this triad are the focus of cognitive DIRECTIONS
theory and treatment.
Cochran (1984) found that the addition of a As we have seen, the affective disorders
six-week cognitive therapy component reduced comprise a multifaceted, heterogeneous group.
medication noncompliance, as well as the Heterogeneity is seen in the variety of causal
frequency of hospitalizations, during a six- influences, and in the perspective that is
month follow-up. More recently, Basco and achieved by examining mood disorders from
Rush (1996) and Newman and Beck (1992) have diverse vantage points. Indicative of this
given extensive descriptions of adjunctive diversity is the extraordinarily broad array of
cognitive-behavioral programs for bipolar dis- effective treatments, from discussions of erro-
order. The primary goals of these programs are neous thinking in cognitive therapy to the
to educate the patient, to increase adherence to induction of seizures by the electrical stimula-
medication regimens, and to promote the use of tion of the brain.
cognitive-behavioral techniques when con- The greatest progress since the 1950s has
fronted with affective symptoms. Education occurred in diagnostic practices, phenomeno-
about bipolar illness includes instruction in the logical and biological characterizations, and in
self-monitoring of prodromal symptoms. the development of effective treatments. The
Awareness of subtle changes in symptoms or next half-century should produce further ad-
behaviors can then serve as a warning system for vances in these areas, but we will also witness the
relapse. This warning system can cue the patient emergence of sophisticated and detailed causal
to have their medications monitored or in- theories that draw from the successes of the last
creased. Efforts to facilitate adherence to half-century, especially once clarification is
medication regimens include addressing patient obtained about the subtypes of affective
concerns and beliefs about medication. Beha- disorder. Genetic research, in particular, will
vioral techniques, such as pairing medication inform us about the mechanisms involved in the
intake with another daily activity, are used to development of brain processes in a person who
ensure that medication is taken regularly. is vulnerable to affective disturbance. Studies of
Cognitive therapy also focuses on the cogni- the early social factors that lead to vulnerability
tive distortions of manic patients. For example, in adulthood will also be critical in this period,
feelings of grandiosity are perpetuated by as will research that yields more detailed
magnification of the positive and minimization understandings of the psychological states that
of, or obliviousness to, negative feedback. predispose a person to mood disorder.
Paranoid thinking in mania is reinforced by Attempts to understand affective disorders
selective attention to evidence that confirms will succeed only if knowledge is integrated from
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the biological and adoptive families of adopted indivi- Winokur, G., Cadoret, R., Dorzab, J., & Baker, M. (1971).
duals with affective disorders. Archives of General Depressive disease: A genetic study. Archives of General
Psychiatry, 43, 923±929. Psychiatry, 24, 135±144.
Wertham, F. I. (1928). A group of benign psychoses: Young, M. A., Fogg, L. F., Scheftner, W., Fawcett, J.,
Prolonged manic excitements. American Journal of Akiskal, H., & Maser, J. (1996). Stable trait components
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6.17
Obsessive-compulsive Disorder
GAIL S. STEKETEE
Boston University, MA, USA
and
RANDY O. FROST
Smith College, Northampton, MA, USA

6.17.2 SYMPTOMS AND CHARACTERISTICS OF OCD 368
6.17.2.1 Symptoms and Diagnosis of OCD 368
6.17.2.2 Differential Diagnosis 369
6.17.3 EPIDEMIOLOGY 369
6.17.3.1 Sex Ratio and Age of Onset 369
6.17.3.2 Clinical Course 369
6.17.3.3 Demographic and Cultural Variables 370
6.17.4 COMORBIDITY AND RELATED DISORDERS 370
6.17.4.1 Axis I Disorders 370
6.17.4.2 Axis II Disorders 372
6.17.5 OCD PATIENT CHARACTERISTICS 372
6.17.5.1 Family Factors in OCD 372
6.17.5.2 Personality and Cognitive Characteristics 373
6.17.5.2.1 Overestimation of risk 374
6.17.5.2.2 Responsibility 374
6.17.5.2.3 Controllability of thoughts 374
6.17.5.2.4 Overimportance of thoughts 374
6.17.5.2.5 Tolerance for ambiguity 374
6.17.5.3 Information/Cognitive Processing in OCD 375
6.17.6 THEORETICAL MODELS AND TREATMENTS FOR OCD 376
6.17.6.1 Behavioral Models for OCD 376
6.17.6.2 Behavioral Treatments for OCD 377
6.17.6.2.1 Degree of improvement from ERP 377
6.17.6.2.2 Specific effects of exposure and response prevention 378
6.17.6.2.3 Processes during exposure 378
6.17.6.2.4 Problems in the treatment of pure obsessive symptoms 378
6.17.6.2.5 Variants in delivery of ERP 381
6.17.6.2.6 Group treatment for OCD 381
6.17.6.2.7 Family treatment for OCD 382
6.17.6.3 Cognitive Theories of OCD 383
6.17.6.4 Cognitive Treatments for OCD 384
6.17.6.5 Biological Models of OCD 385
6.17.6.5.1 The role of serotonin 385
6.17.6.5.2 Neuroanatomy of OCD 386
6.17.6.5.3 Genetics 387
6.17.6.6 Biological Treatments for OCD: Medications and Psychosurgery 387
367
368 Obsessive-compulsive Disorder
6.17.6.6.1 Medications 387

6.17.6.6.2 Psychosurgery 389
6.17.6.7 Combined Interventions for Treatment of OCD 389
6.17.7 FUTURE DIRECTIONS 390
6.17.1 INTRODUCTION dismiss than the latter (Dent & Salkovskis, 1986;
Rachman & DeSilva, 1978; Salkovskis &
Since the mid 1960s, many researchers have Harrison, 1984).
invested considerable effort in defining and Unlike most other Axis I disorders, the
characterizing obsessive-compulsive disorder symptoms of OCD vary considerably from
(OCD) and its myriad symptoms, and, perhaps one patient to the next, sharing only the
most importantly, in developing effective treat- disturbing nature of the intrusions and the
ments. The results of these efforts by research- ritualistic efforts to neutralize the obsessions.
ers, clinicians, patients, families, and their Many patients report having more than one
advocates, are that OCD is now a well- type of obsession and ritual, often apparently
recognized condition, with effective and avail- unrelated to each other, although on closer
able pharmacological and behavioral treat- inspection they may share some meaningful
ments. In the late 1990s, newer forms of thematic content. Most obsessions and compul-
medications and of cognitive and behavioral sions can be grouped into categories, somewhat
interventions are under study. Consequently, it more easily by type of ritual than type of
is likely that our knowledge of OCD and how to obsession because of the many variations in the
treat it effectively will continue to expand for latter category. Most common are checking
some time. Below we present established and rituals, which are usually designed to prevent a
recent findings in the study of OCD. particular catastrophe like fire, burglary, caus-
ing someone harm, embarrassing oneself, or
being rejected. Washing rituals serve to remove
6.17.2 SYMPTOMS AND
ªcontaminationº or ªdirtº caused by such
CHARACTERISTICS OF OCD
sources as human or animal body waste,
6.17.2.1 Symptoms and Diagnosis of OCD chemicals, or other substances. In many cases
washing is thought to prevent a feared disaster
According to the Diagnostic and statistical such as disease or debilitation from occurring.
manual of mental disorders (4th ed., DSM-IV) Repeating compulsions are ªmagicalº rituals in
(American Psychiatric Association [APA], which ordinary actions (such as crossing a
1994), obsessions are recurring persistent threshold or lifting an object) are repeated to
thoughts, images, or impulses that are experi- prevent harm from occurring (for example, a
enced at least at some point as intrusive, loved one dying in an accident). Ordering rituals
unreasonable, and distressing. The individual are less common and involve arranging objects
attempts to ignore or suppress these ideas or to to produce symmetry or balance, thereby
ªneutralizeº them using some ritualistic thought relieving a feeling of discomfort. Individuals
or action. Compulsions are repeated behaviors may hoard or collect seemingly useless objects
or mental acts, rigidly or excessively applied to like old magazines and receipts or empty
relieve anxiety provoked by the obsessions. containers to prevent the loss of potentially
Often, these rituals are designed to restore safety important information or to avoid waste.
or to prevent a dreaded event (Rachman, Although subtypes based on obsessive con-
1976a), an intention that is often deliberately tent have been proposed, these have not been
hidden from casual observers and even close widely adopted, probably because they have not
family members. These symptoms interfere with been particularly useful in predicting differen-
the person's normal activities and consume at tial treatment response. Instead, obsessive
least an hour a day. As for many anxiety and phenomena have been merely described. Good-
affective disorders, in the general population, man et al. (1989) developed a useful Symptom
the symptoms of OCD are relatively common, Checklist for this purpose. Their categories
but usually fail to meet the severity and include aggressive or harming obsessions,
interference criteria that characterize the dis- contamination, sexual content, hoarding/sav-
order. It is interesting to note that the content of ing, religious obsessions, somatic concerns, and
clinical obsessive intrusions differs very little a variety of miscellaneous fears about mental
from ordinary intrusive thoughts exhibited by images, numbers, and knowing or saying things,
most people, but the former provoke consider- among others. From a clinical standpoint, it
ably more anxiety and are more difficult to may be useful to determine the patient's
Epidemiology 369
complete list of obsessive and compulsive prevalence rates reported in Canada (Kolada,
symptoms, since these can fluctuate over time Bland, & Newman, 1994), Finland (Vaisaner,
and may be differentially affected by cognitive 1975), Taiwan (Hwu, Yeh, & Chang, 1989), and
and behavioral treatments. Africa (Orly & Wing, 1979). Furthermore, a
An added component of recent diagnostic recent cross-national epidemiological study of
criteria for OCD is determination of ªpoor OCD (Weissman et al., 1994) reported remark-
insightº type, for those who do not recognize the ably similar findings across seven countries
unreasonableness of their behavior (APA, (USA, Canada, Puerto Rico, Germany, Tai-
1994). Historically, OCD was at least partly wan, Korea, & New Zealand), where annual
defined by patients' recognition of the irration- prevalence rates ranged from 1.1 to 1.8, and
ality of obsessions, with those who were lifetime prevalence ranged from 1.9 to 2.5.
convinced of their obsessions considered psy-
chotic or at least ªovervalued ideatorsº (Foa,
1979; Insel & Akiskal, 1986). More recent study 6.17.3.1 Sex Ratio and Age of Onset
indicates that patients range on a continuum
Although early studies found no differences
from complete awareness (insight) to delu-
in the frequency of OCD in men and women
sional, with most having at least some insight
(Black, 1974; Karno et al., 1988), later ones have
(e.g., Kozak & Foa, 1994).
shown a slight preponderance of women among
OCD patients (Rasmussen & Eisen, 1990;
6.17.2.2 Differential Diagnosis Weissman et al., 1994). A number of studies
have noted a preponderance of males with early
According to the DSM-IV, OCD must be onset OCD (Bellodi, Sciuto, Diaferia, Ronchi,
distinguished from several other conditions that & Smeraldi, 1992; Flament et al., 1988;
share similar features. For example, obsessions Rapoport, 1989; Rasmussen & Eisen, 1990).
are defined as mental experiences that are not The mean onset for males ranged from 14 to
merely excessive worries about real-life pro- 19.5 and for females 21.7 to 22 (Bellodi et al.,
blems (e.g., finances, family well-being, health, 1992; Rasmussen & Eisen, 1990, 1992a). There-
etc.) that are characteristic of generalized fore during childhood, boys with OCD out-
anxiety disorder (GAD) or hypochondriasis. number girls by up to 2 to 1.
Likewise, obsessions must be different in Sixty-five percent of OCD patients developed
character from the guilty or depressive rumina- symptoms prior to age 25 while only 15%
tions of those with major depression. Preoccu- developed symptoms after age 35 (Rasmussen &
pations with food, alcohol, drugs, gambling, Tsuang, 1986). Thus, the average age of onset
and buying are sometimes colloquially termed appears to be in the late teens or early twenties
ªobsessionº or ªcompulsion,º but are readily (Tallis, 1995). The latency from onset to help
distinguishable from obsessive fears of contam- seeking is estimated at seven to eight years
ination, causing harm, preventing danger, and (Yaryura-Tobias & Neziroglu, 1983). Onset of
other anxiety-provoking concerns and rituals. symptoms can be either acute or insidious
Such appetitive preoccupations are discussed (Kolada et al., 1994). Some investigators have
further below, along with other impulsive identified precipitants related to changes in life
symptoms and disorders sometimes character- roles or demands (e.g., pregnancy, childbirth,
ized as ªOC Spectrumº disorders. etc.), with symptoms often focusing on content
related to the precipitant (see Diaz, Grush,
Sichel, & Cohen , in press). However, at least
6.17.3 EPIDEMIOLOGY 40% of OCD patients showed no clear-cut
precipitant (Kolada et al., 1994).
Prior to publication of the first Epidemiologic
Catchment Area (ECA) study (Karno, Golding,
Sorenson, & Burnam, 1988; Robins et al., 1984), 6.17.3.2 Clinical Course
the prevalence rates for OCD were believed to
be quite low, and were estimated only from rates In a review of early follow-up studies,
among psychiatric patient populations. The Goodwin, Guze, and Robins (1969) concluded
ECA study was the first to estimate prevalence that there were three types of clinical course in
rates for OCD from community-based samples OCD: a chronic, unremitting course in which
and using DSM-III criteria. Annual prevalence 10±15% of patients show deterioration, an
rates ranged from 0.8 to 2.3%. Lifetime episodic course with periods of complete
prevalence rates ranged from 1.9 to 3.3%, remission, and an episodic course with periods
considerably higher than previously thought of incomplete remission. Eisen and Steketee's
(Karno et al., 1988; Robins et al.). These rates (1997) recent review confirmed some of their
correspond to similar annual and lifetime conclusions: episodic OCD with full remissions
occurs rarely (10±15%), although this percen- tings, and in 1991 Neal and Turner noted that no
tage increased with longer follow-up periods. studies had yet examined treatment for OCD in
Two recent prospective studies of clinical course African-Americans. According to recent re-
assessed OCD symptoms using a Psychiatric search, blacks with washing rituals seek assis-
Rating Scale that allowed determination of tance more often from medical settings such as
whether subjects met diagnostic criteria for dermatology clinics (Friedman, Hatch, Paradis,
OCD, had subclinical symptoms, or remitted Popkin, & Shalita, 1995) and may have more
entirely. Eisen, Rasmussen, Goodman, et al. severe symptom presentations (Chambless &
(1995) observed that 57% of 51 subjects still met Williams, 1995). Symptoms of OCD appear to be
full criteria after two years, although some of recognizable across many disparate cultures.
these had improved substantially. Of the The tendency for some people with OCD to show
remainder, 12% had minimal or no symptoms changing symptoms (e.g., checking to cleaning),
and 31% were partially improved and did not the wide variety and cultural specificity of
meet diagnostic criteria. Once remitted, 48% symptom expression (e.g., fears of penile
later relapsed. A second study of 107 clinic shrinkage in China, fears of leprosy in Africa),
patients followed up to five years after intake and the shifts in the content of obsessional fears
showed a slightly better outlook, probably over time (e.g., from fears of cancer to AIDS-
because of a longer treatment follow-up related fears) suggests that OCD is at least partly
(Steketee, Eisen, Dyck, Warshaw, & Rasmus- influenced by cultural factors (e.g., Weissman
sen, 1996). These patients showed a 22% et al., 1994). Dulaney and Fiske (1994) noted the
probability of full remission and 53% for partial similarities between OCD rituals and religious or
remission. Still, as in retrospective studies, more cultural rituals, while other investigators
than three-quarters remained symptomatic and (Greenburg & Witztum, 1994) have found
at least partially impaired by their symptoms. certain religious practices to be associated with
A number of unsystematic observations symptom expression in OCD (Okasha, Saad,
about the clinical course are worthy of note Khalil, Dawla, & Seif, 1994). Thus, there is little
and further study. It has been observed that evidence that culture is important in the
OCD symptoms can switch (for example, from development of OCD, but it may well influence
cleaning to checking or vice versa), but no the way the disorder is expressed.
systematic research has examined this phenom-
enon (Rasmussen & Eisen, 1992a; Tallis, 1995).
Certain features such as mild level of symptoms, 6.17.4 COMORBIDITY AND RELATED
atypical symptoms, short duration, and good DISORDERS
premorbid personality indicate a favorable 6.17.4.1 Axis I Disorders
prognosis (Kolada et al., 1994). Features
suggestive of poor prognosis include being male Rasmussen and Eisen (1990) reported that
with early onset of symptoms, symmetry or nearly 60% of their OCD clinic patients had at
exactness-related symptoms, symptoms of least one other disorder, and some estimates are
hopelessness, delusions or hallucinations, fa- even higher (e.g., Lucey, Butcher, Clare, &
mily history of OCD, and presence of tics (Eisen Dinan, 1994). A wide variety of Axis I disorders
& Steketee, 1997; Kolada et al.). appear to be associated with OCD, including
anxiety disorders, depression, alcohol abuse
(dependence), eating disorders, Tourette's syn-
6.17.3.3 Demographic and Cultural Variables drome, body dysmorphic disorder (BDD),
hypochondriasis, and schizophrenia. Comor-
Most studies have not found differences in bidity of OCD with other anxiety disorders is
prevalence of OCD based on race (Hispanic, quite high, ranging from 25±60% (Weissman
African-American, whites), religion, or socio- et al., 1994). The highest frequencies are evident
economic status (Burnam et al., 1987; Karno for specific phobias (Karno et al., 1988), with
et al., 1988; Valleni-Basile et al., 1994). How- social phobia and panic disorder co-occurring in
ever, Karno et al. found OCD to be more 10±50% of samples (see Steketee, Henninger, &
common in young, divorced, separated, or Pollard, in press). Interestingly, GAD, which
unemployed subjects and slightly less common shares a ruminative focus with OCD, occurred
among blacks than whites. Although findings infrequently among those with primary OCD
are somewhat conflicting, most studies have (Turner, Beidel, & Stanley, 1992). Family
concluded that patients with OCD had higher studies have also suggested a shared genetic
than average levels of intelligence. vulnerability with other anxiety disorders
Despite approximately equivalent prevalence (Black, Noyes, Pfohl, Goldstein, & Blum, 1993).
rates, clients from minority groups have rarely There is strong evidence for a shared
presented for treatment in mental health set- vulnerability for depression as well, with various
Comorbidity and Related Disorders 371
studies indicating concurrent prevalence rates mania, and exhibitionism. Many studies have
of 12±80% (Steketee et al., in press). Most shown an association of OCD to Tourette's
studies concur that at least one-third of patients syndrome (e.g., Leckman & Chittenden, 1990;
with OCD report histories of clinical depression Pauls, 1990; Robertson, 1991), as well as to
(e.g., Crino & Andrews, 1996; Weissman et al., other tic disorders and Sydenham's chorea
1994), although 25±33% do not report depres- (Rapoport, Swedo, & Leonard, 1992). In view
sion (Rassmussen & Eisen, 1992b; Rasmussen & of observations that one form of Tourette's may
Tsuang, 1986). Interestingly, recent evidence be OCD-related and some OCD cases are
indicates that the frequency of bipolar disorder Tourette's-related (Leckman & Chittenden,
in OCD is similar to that of major depression in 1990), OCD and Tourette's may be different
this group (Kruger, Cooke, Hasey, Jorna, & expressions of a similar underlying genetic
Persad, 1995). The frequency of affective abnormality (Pauls & Leckman, 1986; Pauls,
disturbance in OCD, together with genetic Towbin, Leckman, et al., 1986), for example, in
and treatment response findings, have led some basal ganglia-frontal cortex pathways (Rapo-
to question whether OCD might better be port et al., 1992). There are also reports of
classified as a variant of depression. Crucial to associations between OCD and kleptomania
this issue is whether the depression which (McElroy, Hudson, Pope, & Keck, 1991), and
accompanies OCD is primary or secondary to exhibitionism (Snaith, Baugh, Clayden, Husain,
OCD. Most patients report that the onset of & Sipple, 1983). Although relatively little
depressive symptoms occurred after the onset of empirical research has been done examining
OCD (e.g., Rasmussen & Eisen, 1992b; Wilner, these relationships, enough suggestive evidence
Reich, Robins, Fishman, & van Doren, 1976), exists to warrant a closer examination.
and several investigators have found that DSM-IV diagnostic criteria rule out a
successful treatment of OCD resulted in the diagnosis of OCD if the content of the
reduction of depressive symptoms (e.g., Foa, obsessions or compulsions focus on the primary
Steketee, Grayson, Turner, & Latimer, 1984; symptoms of several other disorders (e.g., eating
Yaryura-Tobias & Neziroglu, 1983). These disorders, body dysmorphic disorder, hypo-
findings, as well as the centrality of anxiety in chondriasis, even if all other inclusion criteria
obsessive thinking and the comorbidity with are met. However, the observed similarity of
anxiety disorders, argue for classification of food-related thoughts in eating disorders to
OCD as an anxiety rather than depressive obsessions has resulted in a substantial body of
disorder. research on the relationship between OCD and
Despite a wide range in the degree of insight eating disorders. Beyond similarities in the
that accompanies obsessions, OCD is relatively nature of the symptoms, this research suggests
rarely accompanied by schizophrenia (Jenike, that OCD symptoms are more prevalent in
1990; Tallis, 1995), although some research eating disorder patients than in controls, and
suggests a link (Yaryura-Tobias, Campisi, that eating disorders are found at a higher rate
McKay, & Neziroglu, 1995). Furthermore, in OCD (8±11%) than in other disorders
Enright (1996) proposed that an information- (Formea & Burns, 1995; Hsu, Kaye, & Weltzin,
processing view could account for both dis- 1993; Kaye et al., 1992). Also suggestive is the
orders. Schizotypy is a normal personality finding that dieting and weight loss can cause
dimension which ranges from healthy to changes in serotonergic activity (Goodwin,
schizophrenic and is proposed as the continuum Fairburn, & Cowen, 1987). Furthermore, there
which links OCD to schizophrenia. Enright and is evidence that behavioral treatments (exposure
Beech (1990) observed that OCD patients had and response prevention) and serotonergic
more schizotypal traits than patients with other reuptake inhibitors (SRIs), both effective in
anxiety disorders (see also Baer & Jenike, 1992), treating OCD, are similarly useful for eating
and, like schizotypal and schizophrenic sub- disorders (Hsu et al., 1993; Rosen & Leitenberg,
jects, had less cognitive inhibition. They 1982). Rothenberg (1986) has suggested that
proposed that obsessional thoughts result from eating disorders are a modern day variant of
a failure in the cognitive inhibition of associa- OCD, and that cultural pressures for thinness in
tions to ongoing stimulation. Further research Western societies lead young women vulnerable
is necessary in order to examine Enright's to OCD to anorexia and bulimia. This reason-
hypothesis more fully. ing is consistent with Weissman et al's. (1994)
A number of impulse control disorders have proposal that cultural influences partly deter-
been found to be comorbid with OCD or to mine symptom presentation.
share common features (Tynes, White, & Similarly, body dysmorphic disorder has
Steketee, 1990) which has led to their labeling been linked to OCD. BDD is characterized by
as ªOC Spectrum Disorders.º These include excessive preoccupation with a presumed defect
Tourette's syndrome, trichotillomania, klepto- in appearance. The obsessional nature of
thoughts about appearance and anxiety-redu- with OCD do not have comorbid OCPD, and
cing behaviors (e.g., mirror checking, asking for for those who have a personality disorder, it is
reassurance) resemble classical OCD symptoms. just as likely to be one other than OCPD.
Simeon, Hollander, Stein, Cohen, and Arono- Interesting, no studies have shown antisocial
witz (1995) found that 12% of OCD patients personality disorder to occur frequently in
were comorbid for BDD during their lifetime, OCD, and Mavissakalian, Hamann, and Jones
and Neziroglu and Yaryura-Tobias (1993) have (1990a) found it to be the least frequent. This
proposed that BDD may actually be a form of finding is consistent with observations that
OCD. Consistent with this notion, Hollander, patients with OCD generally show excessive
Liebowitz, Winchel, Klumker, and Klein (1989) responsibility (see below), a trait quite incom-
found that all five BDD patients in a clinical patible with antisocial behavior.
series responded to SRIs. The most apparent The issue of whether PD is the primary or
difference was that BDD patients showed less secondary disorder when comorbid with OCD
insight into their illness and may suffer from has rarely been addressed. However, findings
overvalued ideas rather than obsessions (Vitiel- such as those by Mavissakalian, Hamann, and
lo & de Leon, 1990). Nonetheless, in reviewing Jones (1990b) that the number of personality
the limited evidence, Hollander, Neville, Fren- disorder diagnoses, and scores on personality
kel, Josephson, and Liebowitz (1992) suggested disorder measures, declined following successful
that considering BDD a subgroup of OCD may treatment for OCD indicate that such traits may
be useful. not be intractable patterns of behavior. In
Hypochondriasis is characterized by particular, avoidant and dependent traits com-
obsessive-like fears of having a serious disease. monly associated with other anxiety disorders
The similarities between hypochondriacal and may merely reflect a general vulnerability to
obsessional symptoms has been noted (Fallon, anxiety and possibly depression, both being
Javitch, Hollander, & Liebowitz, 1991; Tynes responsive to focused treatments. However,
et al., 1990), as has the frequency of somatic some traits such as passive-aggressive beha-
obsessions in OCD patients (Rasmussen & viors, borderline and schizotypal features may
Tsuang, 1986). In one of the few empirical be problematic for treatment outcome (e.g.,
investigations on this question, Barsky, Wy- Baer & Jenike, 1992; Steketee, 1990).
shak, and Klerman (1986) found comorbid
OCD in 9.5% of 42 hypochondriacal patients,
while only 2.6% of a nonhypochondriacal 6.17.5 OCD PATIENT CHARACTERISTICS
control group had OCD. These findings indicate 6.17.5.1 Family Factors in OCD
some association of the two disorders.
Several studies report that the celibacy rate,
6.17.4.2 Axis II Disorders especially among males with OCD who have
early onset, is higher than that found in the
The picture of comorbidity with personality general population (cf Eisen & Steketee, 1997).
disorders (PD) is somewhat more confused. Among those who are married, marital dys-
While it is clear that personality disorders occur function has been observed, but overall marital
frequently in conjunction with OCD, the satisfaction among clinical patients does not
specific type of personality disorder most often differ from the general population (e.g., Riggs,
associated with OCD has varied substantially Hiss, & Foa, 1992). Family members (spouses
from study to study. This is probably a result of and parents) often become quite involved in
relatively small sample sizes and personality patients' symptoms, especially in performance
assessment instruments with lower reliability of rituals and taking over tasks that are difficult
than those used for Axis I disorders. Most or avoided (Calvocoressi et al., 1995; Shafran,
studies of Axis II comorbidity have found that Ralph, & Tallis, 1995). They often modify
over half of patients with OCD also have at least routines to adapt to OC symptoms, sometimes
one diagnosable personality disorder (Baer & to the extent of restructuring household
Jenike, 1992; Cassano, Del Buono, & Catapano, arrangements altogether. Greater family invol-
1993). Along with obsessive-compulsive person- vement symptoms was significantly correlated
ality disorder (OCPD), the most frequently with family dysfunction and negative attitudes
diagnosed personality disorders among patients toward the patient (Calvocoressi et al.). How-
with OCD are avoidant, dependent, histrionic, ever, the marital relationships of patients with
passive-aggressive, and schizotypal personality OCD are no worse than those of the general
disorder. Pfohl and Blum's (1991) conclusion population (Riggs et al., 1992). Family re-
regarding the frequency of PD occurrence in sponses to OCD have been observed to span the
those with OCD may be the most accurate range from accommodating to antagonistic
reflection of current knowledge: most patients toward patients (Livingston-Van Noppen,
OCD Patient Characteristics 373
Rasmussen, Eisen, & McCartney, 1990). In- more risk-aversive, and fathers were more
cluding family members in assessment is critical and perfectionistic than fathers of
recommended, since they may provide impor- control subjects. In a related vein, Hibbs et al.
tant information not volunteered by the patient (1993) and Hibbs, Hamburg, Kruesi, and
(Van Noppen, Steketee, McCorkle, & Pato, Lenane (1993) observed that families of children
1996). with OCD had higher levels of expressed
With regard to etiological factors, a number emotion (criticism and overinvolvement) than
of characteristics of parents have been hypothe- families of control subjects (82% vs. 41%).
sized to play a role in the development of OCD. While the nature and characteristics of the
Rachman (1976a) suggested that among in- families of OCD patients are far from clear,
dividuals with a personal vulnerability (i.e., there is enough clinical observation and pre-
oversensitivity to criticism), certain parental liminary evidence to hypothesize that the
traits may lead to OCD symptoms. He parents of people who develop OCD are more
hypothesized that parents of OCD cleaners likely to show a constellation of behaviors,
are more overcontrolling and overprotective including perfectionism, overprotectiveness,
and may model excessive cleaning behaviors. overcritical and demanding attitudes, and high
Parents of checkers were hypothesized to set levels of risk avoidance. Once further research
high standards for their children, be over- has established that these characteristics are
controlling and overcritical, as well as modeling more prominent in the families of OCD patients
meticulousness. Other investigations have ob- than in controls, the question of their role in the
served or speculated on similar themes in the development of the disorder can be addressed.
parents of OCD patients, including demanding
or critical attitudes (Clark & Bolton, 1985; 6.17.5.2 Personality and Cognitive
Hoover & Insel, 1984; Kringlen, 1965; Steketee, Characteristics
Grayson, & Foa, 1985); overprotectiveness
(Hafner, 1988; Honjo et al., 1989); perfection- Much of the early description of the
ism (Allsopp & Verduyn, 1990; Honjo et al., obsessive-compulsive personality was tied to
1989; Hoover & Insel, 1984; Lo, 1967; Ras- psychodynamic assumptions of the role of the
mussen & Tsuang, 1986), and rejecting attitudes anal personality in both OCPD and OCD, with
(Emmelkamp, Hoekstra, & Visser, 1985). little distinction made between these two
However, systematic research on hypothesized conditions. The orderliness, parsimony, and
differences between the parents of OCD obstinacy thought to typify people with OCD
patients and controls has been limited. were expanded into more specific personality
Merkel, Pollard, Wiener, and Staebler (1993) traits such as those articulated by Pollack
found that OCD patients perceived their (1987): ªprocrastination, indecision, self-doubt-
mothers to be more overprotective than did ing, driven by obligations and responsibilities,
depressed patients. Contrary to expectation, attempting to attain order and perfection,
however, OCD patients described their fathers bound by routines, uncomfortable and avoidant
as less demanding than did panic disorder of novelty and change, interpersonally formal
patients. Chambless, Gillis, Steketee, and Tran's and even cold, authoritarian and controlling,
(1996) study of parental warmth and over- autocratic, critical, and punitiveº (pp. 249±250).
protection in OCD and agoraphobia indicated Although some of these latter traits better
that parents' and patients' recollections of describe OCPD, others have recently been
parental behavior did not agree. Patients viewed as characteristic cognitive aspects of
reported that their parents most often raised OCD.
them using affectionless control, whereas par- A host of personality/cognitive features are
ents most often rated themselves as having closely linked to OCD (see Reed, 1985; Tallis,
provided optimal parenting. Reports of poorer 1995). Prominent among these are overestima-
parenting were associated with worse social tion of risk, exaggerated responsibility and guilt,
adjustment and higher levels of anxious person- beliefs about the need to control thoughts,
ality disorder characteristics. However, the fusion of thought and action (thinking some-
lack of a normative sample limits conclusions thing makes it so), perfectionism, uncertainty
about the relevance of parenting ratings to and doubt, and intolerance for emotional
obsessive symptomatology. Studying volun- discomfort. These domains were also identified
teers, Frost, Steketee, Cohn, and Griess by a group of international researchers attempt-
(1994) found that subjects with subclinical ing to develop a coherent approach to the
OCD described their parents as more over- assessment of cognitions in OCD (International
protective than nonobsessive-compulsives. OCD Cognitions Working Group, 1996). The
They also found some evidence that both group noted that many of these domains
parents of the subclinical OCD group were overlap considerably. Using an expert consensus
strategy, they selected a subset of five areas and important, and attempt to suppress them. The
defined these in order to generate items for a self- failure of these efforts at suppression results in
report measure of these domains. In discussing sensitization and vigilance to all thoughts
the several cognitive domains listed below that similar to the intrusion. The cycle of attention
may be common features of OCD, we include the to intrusions followed by attempts at suppres-
expert consensus definitions of the working sion are hypothesized to escalate to an obses-
group where relevant. sional pattern (Salkovskis & Campbell, 1994;
Wegner, 1989). The cognition working group
identified a domain of ªneed for controlº and
6.17.5.2.1 Overestimation of risk
defined this as ªovervaluation of the importance
It has long been noted that patients with OCD of exerting complete control over intrusive
exaggerate the probability and severity of bad thoughts, images, and impulses, and the belief
outcomes (Carr, 1971, 1974). Clinical (Rasmus- that this is both possible and desirable.º
sen & Eisen, 1989) as well as empirical (Steketee Dimensions of the need to control were
& Frost, 1994) evidence supports the hypothesis considered to include tracking mental events
that people with OCD are risk-aversive. An and hypervigilance; moral consequencesÐ
expert working group defined threat over- control as a virtue; psychological and behavior-
estimation as ªexaggeration of the probability al consequencesÐinsanity, decreased ability to
or severity of harm believed to result from or function; and immediate efficiency and future
follow intrusive internal experiencesº (Obses- success of control efforts.
sive Compulsive Cognitions Working Group
1997).
6.17.5.2.4 Overimportance of thoughts
The reasons for the overimportance of
6.17.5.2.2 Responsibility
intrusive thoughts and the perceived necessity
Overimportance assigned to intrusive for controlling them may lie in a belief about the
thoughts and an exaggerated sense of respon- meaning of these thoughts. Rachman and
sibility for harm coming to self or others are others proposed that people with OCD tend
closely related cognitive features widely noted in to believe that simply having a thought,
the OCD literature (Freeston, RheÂaume, & particularly an unwanted and objectionable
Ladouceur, 1996; Rachman, 1993). Salkovskis thought, is morally equivalent to engaging in the
(1985) argued that exaggerated responsibility is objectionable act (Rachman, Thordarson, Sha-
central to the symptoms of OCD, and empirical fran, & Woody, 1995). That is, thinking some-
literature supports its importance in OCD (cf thing morally reprehensible is just as bad as
Lopatka & Rachman, 1995; Rachman, 1993; doing it. Evidence for such ªthought-action
Salkovskis, 1985). Closely related to responsi- fusionº (TAF) can be found in the perception of
bility is the emotional experience of guilt. People OCD patients that imagined negative events are
with OCD have been found to score signifi- more likely actually to occur (Rachman,
cantly higher than other groups on measures of Shafran, et al., 1995). Such beliefs that thoughts
guilt (Frost, Heimberg, Holt, Mattia, & Neu- can influence the probability of occurrence of
bauer, 1993; Niler & Beck, 1989; Steketee, negative events may be a part of an exaggerated
Quay, & White, 1991). Salkovskis' and others' sense of responsibility (for negative thoughts
definition of responsibility adopted by the and events) by people with OCD. Recent
working group was ªthe belief that one has attempts to measure and study TAF support
power which is pivotal to bring about or prevent the importance of this construct (Rachman,
subjectively crucial negative outcomes. These Shafran, et al., 1995; Shafran, Thordarson, &
outcomes are perceived as essential to prevent. Rachman, 1996). The Obsessive Compulsive
They may be actual, that is, having conse- Cognitions Working Group (OCCWG, 1997)
quences in the real world, and/or at a moral identified ªoverimportance of thoughtsº as a
levelº (Salkovskis, Rachman, Ladouceur, & central feature of OCD and defined this as a
Freeston, 1992). ªbelief that the presence of an intrusive thought
per se gives it significance or means that it is
important. This includes concepts of thought/
6.17.5.2.3 Controllability of thoughts
action fusion, Cartesian reasoning, and magical
Another important cognitive feature of OCD thinking.º
is disruption in the control of thoughts. Clark
and Purdon (1993) suggested that in normal
6.17.5.2.5 Tolerance for ambiguity
cognitive processing, irrelevant and intrusive
thoughts are simply ignored, whereas indivi- Part of the construct of perfectionism (Frost,
duals with OCD attend to them, consider them Marten, Lahart, & Rosenblate, 1990), one that
OCD Patient Characteristics 375
is perhaps more uniquely tied to OCD, is the mixed, although most studies reported poorer
experience of doubt about the veracity of memory functioning, especially visual memory
experience and the quality of one's actions. (e.g., Boone, Ananth, Philpott, Kaur, & Djen-
Although not part of the formal diagnostic deredjian, 1991; Christensen, Kim, Dysken, &
criteria, doubting is a hallmark of OCD (Reed, Hoover, 1992; Martinot et al., 1990; for an
1985). Doubt about the validity of experience exception see Constans, Foa, Franklin, &
can leave one uncertain about whether actions Matthews, 1995). Research has consistently
are appropriate or adequate to ward off danger. shown lowered confidence in memory capacity
The need for absolute certainty or the inability but not worse reality monitoring (Brown,
to tolerate uncertainty is also a commonly noted Kossyln, Breiter, Baer, & Jenike 1994; Constans
feature of OCD (Kozak, Foa, & McCarthy, et al., 1995; McNally & Kohlbeck, 1993; Sher
1987; Rasmussen & Eisen, 1990). Guidano and et al., 1983).
Liotti (1983) suggested that doubt stems from a Consistent with hypotheses about memory
belief that every situation has a perfect solution dysfunction in OCD, Reed (1985) also argued
and the person with OCD will not feel that such patients fail to categorize and integrate
comfortable unless that perfect solution is information, leading to underinclusive categor-
found. Others have suggested that the need ization in which many small categories are
for certainty maintains ritualistic behaviors generated with narrow boundaries and over-
which must be repeated because certainty has specified rules for category membership. Per-
not been achieved (Beech & Liddell, 1974). Such sons and Foa (1984) found some empirical
doubt is believed to be the root of the indecision support for this notion, and Frost and Hartl
seen in people with obsessive-compulsive ten- (1996) have described this as a nettlesome
dencies (Frost & Shows, 1993). The working problem for compulsive hoarders. Because of
group identified intolerance of ambiguity as a general failure to recognize reasonable bound-
encompassing ªbeliefs about the necessity of aries for categories and experiences, OCD
being certain, about the capacity to cope with patients create artificial structures to govern
unpredictable change, and about adequate their behavior. Thus, rituals, particularly check-
functioning in situations which are inherently ing rituals, are attempts to create an artificial
ambiguous.º structure to determine the end of a sequence of
behaviors.
6.17.5.3 Information/Cognitive Processing in Other theorists have emphasized deficits in
OCD attentional processing in OCD. Enright and
Beech (1990, 1993a, 1993b) proposed an
Quite apart from personality traits and beliefs information-processing theory of OCD which
which characterize OCD, several information- focuses on deficits in selective attention. They
processing capabilities have been hypothesized hypothesized that OCD patients fail to ade-
to distinguish OCD patients from nonpatients. quately inhibit irrelevant stimuli during normal
These processes involve memory, categoriza- cognitive processing, interfering with their focus
tion, and attention. Reed (1977) suggested that a on relevant stimuli. Consequently, processing of
ªpathologically faulty memoryº was a central ordinary information requires a more conscious
feature of OCD. Patients with OCD may suffer and effortful strategy, and suppression of
from deficits in memory for actions (especially irrelevant or unwanted thoughts is more
among those with checking rituals, general difficult. The same cognitive inhibition deficit
memory, confidence in memory functioning, is hypothesized to characterize schizophrenia
and reality monitoring (distinguishing actual and schizotypal personality disorder (Enright,
from imagined actions). For nonclinical com- 1996). Enright and Beech (1993a, 1993b) report
pulsive checkers, several studies have established several studies which support their hypotheses
the presence of deficits in memory for discrete using a negative priming paradigm.
actions performed (e.g., Rubenstein, Peynircio- Another approach to studying attentional
glu, Chambless, & Pigott, 1993; Sher, Frost, processes in OCD has been to examine the
Kushner, Crews, & Alexander, 1989; Sher, processing of fear-relevant information, mainly
Frost, & Otto, 1983). However, among clinical using a Stroop task in which subjects observe
patients, this finding is less consistent, with one fearful and nonfearful words presented in
study supportive and another failing to replicate different colors, and are asked to name the
(see Tallis, 1995). With respect to general color of the word, thereby inhibiting processing
memory deficits, similar findings have emerged of its meaning. Fearful word meanings should be
from neuropsychological studies of OCD. harder to inhibit and therefore take longer.
Nonclinical subjects showed poorer overall Consistent with this hypothesis, Foa, Ilai,
memory functioning (e.g., Sher et al., 1989), McCarthy, Shoyer and Murdock (1993) found
whereas findings for clinical patients were more that OCD washers took longer to name
contamination words than neutral words, and improved were not considered impressive (see
that patients with other types of fears did not Cawley, 1974). Not surprisingly, OCD gained a
show such an effect, supporting the specificity of reputation as intractable (e.g., Coryell, 1981).
the processing effect. Lavy, van Oppen, and van Early behavioral treatments (thought stopping,
den Hout (1994) found that OCD subjects aversion therapy) based on contingent reinfor-
selectively attended to negative OC-related cement and punishment models were also
words (e.g., disease, disaster) but did not show successful for only a limited group of patients,
an attentional bias to positive ones (e.g., clean, often fewer than 50% (Emmelkamp & Kwee,
precise). Of considerable interest is Foa and 1977; Kenny, Mowbray, & Lalani, 1978; Stern,
McNally's (1986) observation that after success- 1978). Interestingly, early efforts to utilize
ful treatment OCD patients no longer showed conditioning models alone (systematic desensi-
attentional bias toward contamination items in a tization, paradoxical intention, repeatedly ver-
dichotic listening task. balizing obsessive thoughts) improved the
The above research findings provide some situation only slightly (Beech & Vaughn,
confirmation of OCD deficits in memory for 1978; Emmelkamp & Kwee, 1977; Solyom,
actions and in general memory. Decreased Garza-Perez, Ledwidge, & Solyom, 1972). In
confidence in memory functioning is evident the late 1960s and early 1970s newly developed
in clinical samples, but not problems in intensive behavioral treatments that incorpo-
distinguishing actual from imagined actions. rated both conditioning models and negative
Problems with overspecification in categoriza- reinforcement notions showed considerable
tion have been observed, and OCD patients also promise. Labeled exposure and response (ritual)
show problems in inhibiting attention to prevention (ERP), these strategies were derived
irrelevant information and in attending to from learning theory models discussed below.
relevant ones. Specific causes for these difficul- The first part of a two-stage theory for
ties will require further research. acquiring and maintaining fear and avoidance
behavior posits that an otherwise neutral event
acquires the capacity to provoke fear because of
6.17.6 THEORETICAL MODELS AND its pairing with an aversive experience, much as
TREATMENTS FOR OCD a dog phobia might develop from being bitten
The review presented below includes three (Dollard & Miller, 1950; Mowrer, 1960).
major theoretical models for the development Evidence supporting this fear acquisition pro-
and maintenance of OCD, followed by treat- cess is inadequate, since many patients cannot
ment methods that are generally derived from recall conditioning experiences associated with
these models. We then present evidence for their symptom onset, and although onset often
effectiveness. We begin with behavioral theories follows very stressful life events, it rarely does
and treatments, followed by a discussion of so immediately, as postulated by the traumatic
newer cognitive models and derived treatments, onset theory (e.g., Rachman & Wilson, 1980). A
and biological models and pharmacological more likely explanation is that stressful events
treatments for OCD. In juxtaposing models sensitize some individuals to cues that have an
with treatment methods, some anomalies in the innate tendency to elicit fear, were learned
practical application of methods derived from during early traumatic experiences, or have
theory will be apparent. In the case of biological special cultural significance (Rachman, 1971;
theories, the discovery of effective treatments Teasdale, 1974; Watts, 1971). Observational or
(serotonergic reuptake inhibitors, SRIs) have informational learning may also account for
partly driven speculations about explanatory some OCD onsets (Foa & Kozak, 1985; Rach-
models such as the role of serotonin. At the end man, 1977), particularly when clients report that
of this section, we examine combined behavioral their symptoms resemble their parents' beha-
and pharmacological treatments and follow this vior. For example, hoarding rituals may mimic a
with an effort to determine the comparative cluttered home resulting from excessive saving
efficacy of behavioral, cognitive, and pharma- by a parent of unneeded but ªpotentially usefulº
cological treatments and their combinations. objects.
In the second stage of the two-factor model,
6.17.6.1 Behavioral Models for OCD any actions (escape or avoidance behavior,
compulsions) that relieve obsessive anxiety/
Early psychological conceptualizations of the discomfort are negatively reinforced because
development of OCD were based mainly on they result in reduction of discomfort. Their
psychodynamic models. However, although demonstrated ability to terminate unpleasant
treatments derived from these models lead to experiences renders them very likely to be
some improvement, more for outpatients than repeated in future situations. As Foa and Kozak
inpatients, average rates of approximately 60% (1985) have noted, both external cues (objects or
Theoretical Models and Treatments for OCD 377
situations) and internal triggers (thoughts, tion of the negative mood generated by
images, or impulses) can produce obsessive obsessions. This ERP treatment has been widely
discomfort. Many of these triggers (e.g., locking studied and found highly effective, although as
the front door) cannot be avoided and therefore for medication treatment, residual symptoms
passive avoidance behaviors which enable and treatment refractory cases plague the field.
phobics to manage their fears are often Salient research on ERP and its components are
insufficient to control anxiety for those with described below.
OCD. More active compulsions are needed to Considerable improvement in effectiveness of
prevent harm or restore a feeling of safety treatments came with the systematic application
(Rachman, 1976a). of prolonged exposure to obsessions and
Substantial evidence supports a behavioral blocking or prevention of compulsions. Meyer
view of OCD as a functional anxiety-based and his colleagues are credited with develop-
disorder in which obsessions increase discom- ment of effective ERP treatment with hospital
fort and compulsions reduce it. In the labora- patients who feared contamination and hand
tory, production of obsessive thoughts washing rituals (Meyer & Levy, 1973; Meyer,
increased heart rate and skin conductance more Levy, & Schnurer, 1974). Using a strict and
than neutral thoughts (e.g., Boulougouris, intensive program of daily direct contact with
Rabavilas, & Stefanis, 1977), and contact with contaminants and complete prevention of
contaminants also increased subjective and rituals (turning off plumbing in patients' rooms
physiological anxiety reactions (Hodgson & and having nurses observe all washing), these
Rachman, 1972; Hornsveld, Kraaimaat, & van investigators reported that 10 of their 15
Dam-Baggen, 1979). Corresponding to the patients were much improved or symptom-free,
second stage of the behavioral theory, complet- and the remaining five were moderately im-
ing compulsions reduced anxiety in most proved. Only two relapsed after five to six years.
instances (e.g., Hodgson & Rachman, 1972; Not surprisingly, such remarkable results led to
Hornsveld et al., 1979). Occasionally reported many investigations of ERP in inpatient and
increases in discomfort following compulsions outpatient settings in several countries. To date,
appear to be frustration reactions to having to approximately 30 open trials and controlled
complete time-consuming unwanted behaviors. studies representing over 600 clients with OCD
Thus, evidence supports a two-stage behavioral have reported good outcomes with variants of
model characterizing the maintenance of OCD ERP. Tables detailing the outcome of these
symptoms, but it does not account for many studies are available in a review by Steketee and
instances of onset unless other explanatory Shapiro (1993). Highlights of findings from
variables are added. these studies along with their clinical implica-
tions, particularly for variations of ERP, are
discussed below.
6.17.6.2 Behavioral Treatments for OCD
6.17.6.2.1 Degree of improvement from ERP
Treatment strategies that follow logically
from the model attempt to disconnect obses- A series of early studies of inpatients by
sions from their associated discomfort (decon- Rachman, Marks, and colleagues at the
ditioning), rendering them more like intrusions Maudsley Hospital in London indicated that
in normal samples, and to eliminate rituals that 15 sessions of exposure and blocking over a
reinforce obsessive fears. In an elaboration on threec-week period was considerably more
this two-factor model, Foa and Kozak (1985) effective than relaxation training, and overall
concurred with Peter Lang's theories that fear effectiveness was excellent even two years later
or anxiety could be viewed as a memory (Marks, Hodgson, & Rachman, 1975). Seventy-
network containing representations of concrete five percent of patients were responsive to ERP,
stimuli, associated physiological responses, and and the majority showed substantial change.
meanings assigned to these (cognitive elements). This improvement rate has been replicated
Correction of all three components would be across numerous studies using 10±20 sessions of
necessary to eliminate fear, although exposure treatment. On average, 85% of clients were at
to at least one part of the network might evoke least ªimprovedº immediately after treatment,
other elements. Following from both models, and about 55% fell into the ªmuch improvedº
behavioral intervention for obsessions and or ªvery much improvedº categories, implying
chronic rituals involves exposure to overt and that target symptoms improved by more than
covert cues that provoke obsessions and half (Steketee, 1993). At follow-up, improve-
blocking of rituals (response prevention) to ment rates remained high, averaging about
prevent them from prematurely reducing ob- 75%, and 50% in the ªmuch improvedº or
sessive fears and thus interfering with habitua- ªvery much improvedº groups. Thus, results
were largely maintained with some relapse obsessions. The addition of the missing compo-
evident and some clients needing additional nent led to maximum improvement in both
therapy (Emmelkamp, Visser, & Hoekstra, symptoms (Foa et al., 1984; Foa, Steketee, &
1988; Foa & Goldstein, 1978). Milby, 1980). These findings support the
With regard to symptom improvement, the suggestion that exposure and prevention of
most positive results were evident on target rituals operate by separate mechanisms.
ratings of treated obsessions and compulsions,
where the average degree of benefit immediately
6.17.6.2.3 Processes during exposure
after ERP ranged from 40%±75% (Steketee &
Shapiro, 1993). On other standardized self- Foa and colleagues have suggested that
report measures, the level of improvement was effective ERP relies on subjective and physio-
slightly lower. At follow-ups ranging from three logical processes activated by exposure and
months to six years, treatment gains were only blocking, that reflect the processing of emo-
slightly different across studies, falling in the tional information pertinent to the obsessive
45±70% range for target symptoms, and symptoms. These processes include activation
averaging 50% improvement for questionnaire of obsessive anxiety (reactivity) and gradual
measures. The consistency of ERP results and decrease (habituation) of these reactions during
the degree of benefit across multiple treatment exposure, as well as across exposure sessions
sites and countries is quite impressive, clearly (Foa & Kozak, 1986). Habituation during direct
indicating that exposure and response preven- imagined exposure, and habituation across
tion is an effective treatment for OCD symp- sessions, have been demonstrated (Grayson,
toms. However, the above summary does not Foa, & Steketee, 1982; Shahar & Marks, 1980)
address the question of how many of these and associated with more change in therapy
treated patients no longer meet criteria for the (Foa, Steketee, Grayson, & Doppelt, 1983;
diagnosis of OCD or no longer require inter- Kozak, Foa, & Steketee, 1988). Habituation
vention for their symptoms. Some more recent rates may vary as a function of the intensity of
investigations have assessed improvement using arousal (Foa et al., 1983; Kozak et al., 1988).
the standardized Yale±Brown Obsessive Com- Therefore clinicians can use intensity of arousal
pulsive Scale (YBOCS) in which scores corre- and habituation rates to judge the course of
spond closely to diagnostic categorizations (16 therapy and make adjustments in the type and
and above usually meets criteria for OCD). length of exposure necessary. Findings by
Outcomes of studies using the YBOCS to assess Grayson and colleagues regarding the benefits
ERP treatment are presented in Table 1. of attention-focusing versus distraction from
exposure (e.g., Grayson, Steketee, & Foa, 1986),
suggest that in standard clinical practice
6.17.6.2.2 Specific effects of exposure and
therapists are advised to ask clients to concen-
response prevention
trate on their fears during exposure, and avoid
Examining the separate effects of exposure distracting conversation that might interfere
and response prevention on obsessions and with the processing of fearful information.
compulsions, Foa and colleagues, as well as
other investigators, found support for the
6.17.6.2.4 Problems in the treatment of pure
behavioral model from which ERP is derived.
obsessive symptoms
In their first trial with 21 patients (Foa &
Goldstein, 1978), 86% had stopped ritualizing Early evidence indicated that patients with
after treatment, but only 57% improved sub- obsessions but no overt compulsions tended to
stantially on obsessions, suggesting that com- have poorer outcome than those with clear
pulsions responded more to ERP than rituals (e.g., Emmelkamp & Kwee, 1977; Rach-
obsessions. According to behavioral theory, man, 1976b). A possible reason for their failure
exposure should particularly reduce anxiety to respond consistently to exposure treatment is
associated with obsessions, whereas prevention that obsessions alternated with undetected and
of ritualistic behavior should influence rituals untreated mental rituals (see Salkovskis &
more than obsessions. This dual hypothesis was Westbrook, 1989; Steketee & Foa, 1985). In
supported in multiple case studies of OCD such cases, prolonged exposure might actually
patients (Mills, Agras, Barlow, & Mills, 1973; have strengthened mental rituals by repeatedly
Turner, Hersen, Bellack, Andrasik, & Cappar- provoking them and thereby preventing habi-
ell, 1980), as well as in group trials. Both tuation of obsessions, consistent with Salkovs-
interventions delivered separately reduced ob- kis and Westbrook's (1989) observation that
sessions and rituals, but exposure affected following an obsessive thought with a ªneu-
subjective anxiety more than rituals, and tralizingº one (mental ritual) actually increased
response prevention reduced rituals more than discomfort. According to behavioral theories of
Table 1 Studies of treatment outcome for OCD using YBOCS assessment and Clinical Improvement Scales.
Percentage of
subjects clinically
Study # of # of YBOCS YBOCS YBOCS Time of improved post-test
(Year) N Treatment Type sessions weeks pretest post-test follow-up follow-up follow-up Comments
Jenike et al. 18 SRI Fluv 10 22.6 18.8

(1990) (3.5) (4.0)
Greist et al. 160 SRI Fluv 10 23.3 18.4 38b
(1995) (4.8)
Freeman et al. 34 SRI Fluv 10 26.2 17.7 59b
(1994) 32 SRI Cmi 10 25.5 17.6 53b
Clomipramine 118 SRI Cmi 12 10 26.3 16.2 60b*
Collaborative (5.5) (0.7) * combined % from both sides
Study Group 134 SRI Cmi 12 10 26.2 14.7
(1991) (4.9) (0.7)
Jenike et al. 13 SRI Cmi 10 24.1 15.2
(1989) (5.8) (5.2)
61 SRI Fluox 12 22.2 13.9
(6.2) (7.0) depressed pts did not differ from
nondepressed
Tollefson et al. 90 SRI Fluox 8 13 24.4 16.8 38b*
(1994) (60mg/d) (5.1) (7.8) * at all doses, a greater proportion
of Ss who took Fluox showed
more clinical improvement than
control (clinical improvement:
35% > baseline)
Goodman 21 SRI Fluv 8 25.0 14.3
et al. (1989) (6.0) (7.0)
Chouinard 43 SRI Ser 5 8 23.4 19.6 56 or 25?b
et al. (1990) (4.9)
Greist et al. 80 SRI Ser *7 12 23.6* 16.1* 17.3 48 weeks 39b
(1995) 200mg/d * estimated from graph
Jenike et al. 10 SRI Ser 6 10 22.8 20.6
(1990) (6.0) (9.2)
Table 1 (continued)
Percentage of
subjects clinically
Study # of # of YBOCS YBOCS YBOCS Time of improved post-test
(Year) N Treatment Type sessions weeks pretest post-test follow-up follow-up follow-up Comments
Orloff et al. 85 SRI Mixed 10+ 23.7 ± 10.1 1±3.5

(1994) (6.7) (7.0) year Chart review method, 29% also
had 10+ hours of ERP, most pts
still on meds.
Krone et al. 17 ERP- Indiv 7 7 20.4 17.2 (6.9)
(1991) without meds* (6.3) * 55% were already on SRIs
18 ERP- Indiv 7 7 21.9 15.1 11.6* 3 months
with meds (6.6) (6.1) (6.4) * Follow-up is for all subjects
(n=24) on or off meds.
Steketee et al. 45 ERP Indiv* 22 16 24.4 15.1 14.5 3 months
(1995) (5.4) (7.2) (7.9) * Some subjects on SRIs; at 3
month follow-up n=34
Hiss et al. 8 ERP+RP* Indiv 19+ 9- 4 12 23.1 8.8 8.1 6 months
(1994) phone (5.4) (4.5) (7.1) * RP + Relapse prevention
10 ERP+AT* Indiv 19 4 23.9 9.8 13.4 6 months
(7.3) (7.2) (8.8) * AT=Associative therapy
(placebo)
Fals-Stewart 30 ERP Indiv 24 12 20.2 12.1 12.9 6 months
et al. (1993) (4.0) (3.7) (3.5)
31 ERP Group 24 12 22.1 12.0 14.0 6 months
(4.1) (3.4) (3.6)
Van Noppen 17 ERP Group 10 10 23.9 16.6 14.5 1 year 31a 43a
et al. (1996) (7.2) (7.2) (7.3)
19 ERP Multi- 10±12 10±12 23.9 15.6 14.9 1 year 47a 58a
family (5.4) (6.5) (7.8)
Van Oppen 29 ERP Indiv 16 16 25.4 17.3 28a
et al. (1995) (7.0) (8.3)
28 COG Beckian 16 16 24.1 13.3 50a
(5.5) (8.5)
ERP = exposure and response prevention, Fluv = fluvoxamine, Cmi = clomipramine, Fluox = fluoxetine, Ser = sertraline, SRI = serotonin reuptake inhibitor, COG = cognitive therapy, YBOCS = Yale±Brown Obsessive
Compulsive Scale. a Jacobson and Truax method. b Clinical Global Improvement rating.
OCD, effective treatment would require that Direct (in vivo) exposure has been delivered in
exposure be applied only to obsessive thoughts, nearly all studies of ERP, but some studies have
and mental compulsions should be blocked also included imagined exposure or have
(e.g., by thought stopping, distraction, or compared these variants. Findings indicate that
substitution). Several researchers have demon- direct exposure is needed (Rabavilas, Boulou-
strated the success of such a strategy especially gouris, & Stefanis, 1976) and that imagined
using uninterrupted audiotaped exposures to exposure may confer added benefits, particu-
narrated obsessions (e.g., Rachman, 1976c; larly at follow-up, for those patients for whom
Salkovskis & Westbrook, 1989). catastrophic outcomes are salient components
of their obsessions (e.g., Foa, Steketee, &
Grayson, 1985). From the above findings it
6.17.6.2.5 Variants in delivery of ERP
appears that 10±20 sessions of self- or therapist-
Several variations on ERP procedures have controlled ERP applied one to five times per
been studied. Emmelkamp and colleagues in week provides an adequate trial of ERP for
Holland reported positive effects for a home- most patients with OCD. Longer direct ex-
based therapy using ERP without the careful posure sessions or assignments (generally about
monitoring of in vivo exposure and rituals an hour) are more advisable than short
carried out with hospitalized patients (Boersma, exposures (Rabavilas et al., 1976) to permit
Den Hengst, Dekker, & Emmelkamp, 1976). In reduction in their obsessive anxiety. Imagined
a controlled study, therapist-directed exposure exposure may be added for patients with
did not improve on the outcome of self- problematic catastrophic fears.
controlled treatment (Emmelkamp, van den
Heuvell, Ruphan, & Sanderman, 1989) and the
6.17.6.2.6 Group treatment for OCD
latter may have produced more durable gains
(Emmelkamp & Kraanen, 1977). In Kirk's Group interventions for delivering ERP have
(1983) efforts to apply ERP to consecutive been examined in several studies in an effort to
patients in an outpatient clinic setting, thera- identify cost-effective strategies. Hand and
pists relied more on homework assignments Tichatzky (1979) treated 17 OCD patients in
than on accompanied direct practice to achieve three groups targeting OC symptoms, social
gains, unless progress required the therapist's interaction problems, and problem-solving
presence. Correspondingly, in a third of cases, ability in twice-weekly group sessions contain-
relatives and friends played a significant role in ing in vivo exercises, homework assignments,
assisting in treatment. The deliberate involve- communication skills training, and separate
ment of relatives in behavioral treatment is support group meetings for spouses. Some
described in more detail below. decrease was observed in OCD symptoms and
Dutch investigators also reported that 10 anxiety, but this varied considerably across
sessions of treatment was too short, since on groups. Two smaller case series employed 10±14
average clients required an additional 15 group sessions of education, goal setting,
treatment sessions during follow-up (Emmelk- behavioral skills training, exposure, response
amp, van der Helm, van Zanten, & Plochg, prevention, homework logs, and cognitive
1980). Foa and colleagues concurred, as evident restructuring (Epsie, 1986; Taylor & Sholomos-
from the expansion of their program from 10 kas, 1993). Benefits at the end of treatment and
sessions to 15 sessions plus home visits (see Foa at follow-up were substantial and generally
& Goldstein, 1978; Steketee & Foa, 1985). comparable to individual treatment trials.
Rachman and colleagues observed that 30 Several large trials have been reported.
sessions led to somewhat more improvement Enright (1991) treated 24 patients (approxi-
than 15 sessions, but the gains were not mately six per group) for nine weekly 90-minute
substantial (Rachman et al., 1979). However, sessions using a similar multidimensional beha-
in a clinical study, Kirk (1983) obtained good vioral treatment that included assertiveness
outcome despite the fact that half of the patients training. The author reported significant im-
attended 10 or fewer sessions directed specifi- provement in OCD symptoms and functioning
cally at the OCD symptoms. However, it may be at post-test and six-month follow-up, although
that Kirk's clinic patients would have benefited only 17% were clinically significantly improved.
from more sessions but could not afford the In a second uncontrolled trial, Krone, Himle,
time or money to do so. In research trials, and Nesse (1991) treated 36 OCD patients in
frequency of sessions has not made a difference seven-week groups that included instruction in
in outcome (Emmelkamp et al., 1989), and self-treatment and therapist-directed ERP dur-
examination of the outcome of studies that used ing treatment sessions with an optional family
different frequencies of treatment produced the psychoeducational session. YBOCS scores re-
same findings (Steketee & Shapiro, 1993). duced significantly to below clinical levels at
three-month follow-up, and improvement oc- Hafner (1982) and others (e.g., Cobb,
curred regardless of medication use. In two McDonald, Marks, & Stern, 1980; Hoover &
studies by Van Noppen and colleagues, 10 Insel, 1984) described cases in which patients
sessions of group ERP were used to treat a total improved when spouses or family members
of 90 patients with OCD. YBOCS scores again participated in the behavioral treatment pro-
reduced significantly (an average of 5 to 10 cess. However, group trials that examined
points) and general functioning also improved inclusion of family members in ERP have
(Van Noppen, Pato, Marsland, & Rasmussen, produced mixed results. Although early results
1995; Van Noppen et al., 1996). See Table 1 for by Emmelkamp and DeLange (1983) indicated
details of outcome on YBOCS scores for group that spouse assistance in exposure treatment
ERP treatment. might improve outcome, a second larger study
In the only controlled trial of group ERP, indicated no difference in immediate or follow-
Fals-Stewart, Marks, and Schafer (1993) com- up outcome, despite improvement in marital
pared group ERP with or without imagined satisfaction (Emmelkamp, de Haan, & Hoog-
exposure (N=30) to comparable individual duin, 1990). However, in this trial, treatment
treatment (N=31) and to an individual relaxa- may have been too brief (eight sessions in five
tion control treatment (N=32). Following 24 weeks) to permit differences to be detected, and
sessions over a 12-week period, subjects in both the lack of communication training regarding
exposure treatment conditions improved sig- OCD symptoms (see Emmelkamp, Kloek, &
nificantly in OCD symptoms, whereas the Blaauw, 1992) may have reduced family-
relaxation control group changed only on assisted treatment efficacy. These negative
anxiety. Post-test YBOCS scores fell below findings are contradicted by Mehta (1990)
the clinical range. Individual treatment led to who reported that involving spouses and other
comparable but somewhat more rapid change family members in ERP for 30 patients in India
(see Table 1). Because this study excluded led to significantly greater gains in OCD
patients with major depression and Axis II symptoms, mood state, and social and occupa-
diagnoses, both common in OCD as noted tional functioning, compared with unassisted
above, a replication is needed to determine the treatment. At follow-up, family-treated patients
generalizability of these findings to a more continued to improve, whereas individually
representative sample. Nonetheless, the benefits treated patients lost some gains, suggesting that
of a group modality for delivery of ERP are family involvement may be especially useful in
quite clear. forestalling relapse. An analysis of family
processes affecting outcome indicated that
nonanxious, consistent family members were
6.17.6.2.7 Family treatment for OCD
more successful in providing support and
As noted earlier, researchers have commented supervision than anxious and inconsistent ones,
on the adverse effects of OCD symptoms on especially those who engaged in argument and
family functioning and the often extensive ridicule. The discrepant findings from these
family involvement in patients' OCD symptoms studies could reflect study differences in treat-
(Marks et al., 1975; Calvocoressie et al., 1995). ment length, family role, and cultural differ-
Several researchers have suggested advantages ences in the populations of Western Europe and
for support group involvement of both patients India (see Hafner, 1992).
and family members. In an early study, Marks Thornicroft, Colson, and Marks's (1991)
et al. (1975) employed an open-ended monthly impatient treatment program in the UK
group for family members and patients to emphasized self-treatment and teaching rela-
discuss the effect of OCD on the family and to tives to reduce their involvement in rituals and
plan coping strategies and rehearse behavioral to encourage self-exposure in a noncritical
exercises. More recently, several reports have manner. Relatives practiced these skills under
outlined psychoeducational focuses for time- the therapist's supervision on the ward. Average
limited family support groups, including ses- symptom decreases of 45% at discharge and
sions on diagnosis, assessment, theories of 60% at a six-month follow-up, with clear
OCD, behavioral treatment, medications, and improvement in functioning, indicated good
prevention of relapse (e.g., Black & Blum, 1992; success for this very disabled inpatient popula-
Tynes et al., 1992). Psychoeducational goals tion. Similarly, Van Noppen et al. (1996) treated
included improving self-esteem, sharing feelings 19 patients in three co-therapy groups that
and experiences, accepting patients' realistic included spouses/partners, parents, and other
limitations, and learning strategies for coping relatives in 10±12 two-hour sessions. YBOCS
with OCD symptoms. These reports noted high scores were reduced substantially to below
participant satisfaction with psychoeducational clinical levels and the reductions were still
groups, but provided no outcome data. significant at one-year follow-up. Improvement
was also evident on disability scores. In this era beliefs. They propose that unpleasant or
of managed care, efforts to reduce costs while stressful events produce intrusive thoughts. If
maintaining efficacy argue for the potential irrational beliefs are related to these intrusive
value of group and family behavioral interven- thoughts, they become important and develop
tions for OCD. into obsessions. The above theories are clearly
similar with regard to the specific irrational
6.17.6.3 Cognitive Theories of OCD beliefs hypothesized to be most central to OCD.
As evident below, these proposals have been
A number of cognitive theories of OCD grow largely subsumed by more recent cognitive
out of an appraisal model (Lazarus, 1966) in theorizing.
which appraisals of threat (primary appraisal) The best articulated and experimentally
and appraisals of coping resources (secondary supported cognitive theory of OCD has been
appraisal) are considered central to the devel- proposed by Salkovskis (1985, 1989) who has
opment of OCD. As noted earlier, Carr (1974) drawn heavily from Beck's (1976) cognitive
observed that obsessive compulsives make theory of emotional disorders. In this model,
abnormally high estimates of the probability Salkovskis relies on extensive research showing
of unfavorable outcomes. That is, they more that intrusive cognitions are normal phenomena
often anticipate danger or negative outcomes experienced by over 90% of the population
than do nonobsessionals. Carr (1974) suggested (e.g., Freeston, Ladouceur, Thibodeau, &
that compulsive behaviors are intended to Gagnon, 1991; Rachman & deSilva, 1978;
reduce the threat created by this erroneous Salkovskis & Harrison, 1984). Thus, what
judgment of risk. McFall and Wollersheim distinguishes people with OCD is not the
(1979) expanded on this idea and theorized that experience of intrusive thoughts, but the way
the overestimate of threat by patients with OCD in which their occurrence and content are
is part of an inaccurate primary appraisal interpreted. While most people simply are
process (cf Lazarus, 1966) which contributes surprised by and merely ignore these intrusions,
to the development of OCD. They proposed people with OCD ascribe special importance to
that four types of beliefs or assumptions them. According to Salkovskis, a set of under-
contribute to inaccurate appraisal and result lying beliefs determines the reaction to negative
in the overestimation of negative outcomes. intrusive experiences in people with OCD.
These include beliefs about the need for perfect These underlying beliefs are characterized by
competence to feel worthwhile and avoid an exaggerated sense that one is responsible for
criticism; that making mistakes or failing to harm to oneself or others and must act to
meet one's ideals should result in punishment or prevent it. When the intrusive thought is
condemnation; that one has power to prevent interpreted in this light, the person seeks to
disastrous outcomes by magical rituals; and that reduce the discomfort by engaging in some form
certain thoughts and feelings are unacceptable, of neutralization (i.e., compulsion, suppression,
potentially catastrophic, and worthy of punish- or avoidance). Although the role of responsi-
ment. McFall and Wollersheim also suggested bility in OCD has been described by a number of
that patients with OCD are deficient in previous theorists (Rachman & Hodgson, 1980;
secondary appraisal of their abilities to cope McFall & Wollersheim, 1979), Salkovskis
with threat. refined the concept and elevated it to an
In a very similar vein, Guidano and Liotti explanatory level. This theory suggests that
(1983) outlined a cognitive model of OCD that two things happen in OCD. First, patients
emphasized two primary features: the need for appraise the intrusive thought as an indication
perfection and for certainty to avoid criticism that they are in some way responsible for harm
and risk. These theorists further suggested that or its prevention. Second, this appraisal elicits
three of the irrational beliefs described by Ellis neutralizing behavior (overt or covert). If some
(1962) are especially relevant in OCD. These are other form of negative appraisal occurs without
that one should be thoroughly competent, the appraisal of responsibility, Salkovskis
adequate, and achieving in all possible respects suggests that neutralization will not take place
to consider oneself worthwhile; that one should and the result will be anxiety and/or depression,
be very concerned about potential danger and but not OCD. Thus, the core hypothesis/
dwell on the possibility of its occurring; and that assumption of this model is that OCD symp-
perfect solutions to all problems are available toms are neutralizing efforts to address the
and should be sought. A similar model was also appraisal of responsibility for harm.
proposed by Warren and Zgourides (1991) Responsibility has been discussed already in
whose rational emotive therapy model derives the context of cognitive characteristics of OCD.
from Ellis's concepts. Like other appraisal Neutralization has been defined as ªvoluntarily
models, it also emphasizes the role of irrational initiated and conducted activity which is
intended to have the effect of reducing the cognitive in nature, but have been described
perceived level of responsibilityº (Salkovskis, earlier in the sections on information processing
Richards, & Forester, 1995, p. 285), linking such (Enright, 1996) and biological models (Pitman,
efforts to responsibility. Included in neutraliza- 1987).
tion are overt behaviors (washing, checking, It is clear from the above review that
etc.), as well as mental events, attempts to put observation of patients with OCD have led to
things right, thought suppression, and reassur- a rich variety of theoretical ideas that involve
ance seeking. Consistent with earlier anxiety- cognitive conceptualizations of the origins and
reduction models, Salkovskis et al. (1995) maintenance of this disorder. Although early
suggested that neutralization effectively reduces cognitive treatments were not derived from
the level of perceived responsibility in the short theories that were specific to OCD symptoms,
run, but increases the probability of intrusive more recent studies have examined rational-
thoughts in the longer term. emotive therapy (RET) and Beckian-derived
A great deal of research has been generated by cognitive therapy based somewhat more directly
this model, much of it supporting the basic on some of the above ideas. The effects of these
contention that responsibility is a primary methods are detailed below.
feature of OCD. Experimental manipulations
of responsibility (Lopatka & Rachman, 1995)
and refinements in the nature and measurement 6.17.6.4 Cognitive Treatments for OCD
of obsessional responsibility (RheÂaume, Free-
ston, Dugas, Letarte, & Ladouceur, 1995; Several writers have observed the ability of
Salkovskis et al., 1995) tend to support the exposure-based therapies to modify thoughts
theory. Some revisions and critiques have been and beliefs, particularly those about risk and
proposed. Clark and Purdon (1993) propose danger, merely by requiring clients to remain in
that more emphasis should be given to anxiety-provoking situations until their fear has
dysfunctional beliefs about controlling thoughts subsided. Foa and Steketee (1979) suggested
and the costs of not doing so and to the role of that exposure treatment may not actually correct
depression in actually impairing patients' ability cognitive deficits, but results in reclassification
to control their thoughts. They also suggest that of some contexts as nondangerous. Whether
neutralization is not so much an essential exposure also modifies other types of cognitions
component in the formation and maintenance common in those with OCD is an important
of OCD, but develops only when other thought question only partly addressed in studies by
control efforts fail. O'Connor and Robillard Emmelkamp and Van Oppen. These investiga-
(1995) criticize Salkovskis' theory, concluding tors noted minimal change in the Irrational
that people with OCD do not react to an actual Beliefs Inventory (IBI) following ERP (Em-
feared stimulus, nor to the perceived conse- melkamp & Beens, 1991; Emmelkamp et al.,
quences, but instead to what they imagine might 1988; Van Oppen et al., 1995), but this measure
be there, despite a lack of sensory evidence to may not adequately capture the cognitive
support the belief. This concept is similar to the domains of concern in OCD. The effects of
thought-action fusion in that what is imagined ERP on cognitions requires further study.
seems a real possibility. They argue that a faulty Early studies of the effects of cognitive
inference process is responsible for OCD beliefs, therapies on OCD examined self-instructional
and posit several types of inference errors. For training (SIT) and rational-emotive therapy
example, rather than forming a hypothesis (RET), neither of which was designed especially
about an obsessional fear (the table is dirty) for OCD. SIT consisted mainly of efforts to
and testing it (feeling the table), people with modify self-statements. When combined with
OCD revise the evidence to fit the hypothesis (it ERP, SIT did not improve significantly on the
must be dirty because I can imagine it dirty). outcome of ERP alone (Emmelkamp et al.,
Thus, OCD rituals are attempts to change the 1980). Questioning whether SIT was an appro-
ªfictional narrativeº by altering reality. Further priate cognitive intervention for OCD, Em-
reality testing difficulties are evident in explana- melkamp et al (1988) went on to study the effects
tions for obsessional beliefs that make reference of RET, consisting of disputing irrational beliefs
to superstitions, magical or pseudoscientific and making rational analyses of obsessional
explanations, or rely on information that is situations, compared with self-controlled ERP
irrelevant to the current situation. Further, in 18 patients. Both treatments produced
O'Connor and Robillard propose that OCD significant changes in most measures of OCD
patients make irrelevant or incidental associa- symptoms (average improvement 78%), with
tions between objects or events and use these to continued gains six months later (average
establish links in a way quite similar to improvement 94%) when several clients re-
sympathetic magic. Several other theories are ceived additional therapy. RET demonstrated
some superiority over exposure in improving also reduce relapse. However, some preliminary
depressed mood. In a second study of RET, research establishing which cognitions are
Emmelkamp and Beens (1991) replicated their important in the development or maintenance
earlier findings in 21 clients who were randomly of OCD symptoms, and how to assess these, has
assigned to either cognitive therapy or exposure not yet been completed. Only with such
treatment, followed by the addition of exposure information can researchers begin to determine
treatment for both groups. Significant improve- whether desirable cognitive changes are best
ment was evident in both groups, with no achieved via cognitive treatments or by other
differences between them. RET was just as (e.g., behavioral, biochemical) methods. In the
effective as exposure, and interestingly, com- late 1990s, given the recency of study of
bined treatment did not have an additive effect. cognition and cognitive therapy for OCD, these
Irrational beliefs (again measured by the IBI) methods are not routinely included in standard
declined somewhat more after RET, and behavioral treatment programs. Informally,
interestingly, required longer to improve (four however, many clinicians engage in dialogue
weeks after treatment) than OC symptoms. with clients regarding their beliefs and assump-
Cognitive treatments using Beck's model (see tions as these surface during exposure sessions
Beck, Emery, & Greenberg, 1985), in which and interfere with reduction of anxiety or
faulty beliefs and underlying assumptions are discomfort.
examined and challenged, have been examined
in case studies of OCD patients. Examples of
Beckian cognitive methods are explicated by 6.17.6.5 Biological Models of OCD
Van Oppen and Arntz (1994) and by Freeston,
RheÂaume, and Ladouceur (1996), particularly The discovery of effective pharmacological
for obsessional patients without overt rituals. agents for treating OCD produced a surge of
Kearney and Silverman (1990) reported good interest in biological explanations for the
outcome when they alternated cognitive therapy disorder. With the recent development of
and response prevention for a suicidal adoles- sophisticated instrumentation, methods of test-
cent who refused exposure. When exposure ing and refining hypotheses about neural
therapy was ineffective for contamination fears substrates have produced dramatic advances
related to skin cancer, Salkovskis and Warwick in our knowledge about the biology of OCD.
(1986) found that cognitive therapy altered Current biological models can roughly be
unrealistic beliefs and produced positive gains, organized into two types: neuropharmacologi-
implying possible benefits for OCD patients cal and anatomical. The neuropharmacological
with overvalued ideas. In a recent study of four explanations involve a disregulation of the
patients with checking rituals, cognitive inter- serotonergic transmitter system. The anatomi-
vention focused on excessive responsibility cal explanations involve the basal ganglia,
proved successful without ERP (Ladouceur, orbiotfrontal cortex, and their connecting
Leger, & RheÂaume, 1995). loops. These models are not mutually exclusive.
Two controlled trials have been conducted
using Beck's cognitive methods. Cognitive
6.17.6.5.1 The role of serotonin
therapy using exposure only in the context of
behavioral experiments was compared to ex- The most consistent neuropharmacological
posure alone by Van Oppen et al. (1995). These evidence comes from the results of the admin-
authors found both treatments equally effective istration of serotonin reuptake inhibitors (SRIs)
after therapy and at follow-up, but a trend was as a treatment for OCD (Barr, Goodman, &
evident for slightly better outcome with cogni- Price, 1993). A plethora of evidence now
tive therapy (see Table 1). This trend can be indicates that the SRIs are especially effective
questioned since the effects of ERP in this study in reducing symptoms of OCD (see
were somewhat lower than observed in some Section 6.17.6.6). These findings suggest that
other centers. A second study by Ladouceur, the serotonergic system may be particularly
Freeston, Gagnon, Thibodeau, and Dumont important in the biology of OCD. Unfortu-
(1995) treated 29 ruminators with combined nately, drug response data are not the best
exposure and cognitive therapy in a controlled source of evidence for testing underlying
waiting-list study. The combined treatment neurochemical processes.
produced an 84% success rate and therapeutic More direct evidence for serotonergic invol-
gains were maintained at one-year follow-up. vement require studies of peripheral markers of
From the above reports, it is evident that serotonin (i.e., concentrations of known meta-
treatments designed to correct cognitive distor- bolites of serotonin in the blood or cerebrospinal
tions common in OCD clients enhance im- fluid) or pharmacological challenges (i.e., ad-
mediate outcome with or without ERP and may ministering a serotonin agonist which provokes
a serotonergic response in people whose ser- found increased metabolic activity in the
otonergic system is dysregulated). Unfortu- striatum during exposure among OCD cleaners
nately, studies of blood platelet measures of (McGuire, Bench, Marks, Frackowiak, &
serotonin and cerebrospinal fluid concentra- Dolan, 1994; Zohar, Fux, Taub, & Lusel,
tions of serotonin metabolites (5-hydroxyindole- 1989), but reduced metabolic activity among
acetic acid: 5-HIAA) have been inconsistent in compulsive checkers (Cottraux et al., 1996).
establishing the role of serotonin function in Cottraux et al. (1996) suggest that the latter
OCD (Barr et al., 1993; Rauch & Jenike, 1993). It converse finding may be due to the ability of
is possible that peripheral markers of serotonin compulsive checkers to engage in covert
in a resting state do not show functional neutralization during the PET scan procedure.
differences between OCD and normal subjects In reviewing the evidence on basal ganglia
because the body may compensate for serotonin involvement in OCD, Rauch and Jenike (1993)
dysregulation (Barr et al.). conclude that there is compelling evidence for a
The results of pharmacologic challenge stu- striatal abnormality among OCD patients, but
dies have produced findings opposite to what that it is not clear whether this abnormality is
would be expected based on the evidence from primary or secondary. These studies have led to
drug treatment studies. The effectiveness of SRIs speculation about the role of basal ganglia
suggest OCD patients suffer from a functional dysfunction in the development of OCD. Wise
deficit in serotonin (Yaryura-Tobias & Bhaga- and Rapoport (1989) have postulated that OCD
van, 1977). However, administration of seroto- is a basal ganglia disorder involving the
nin agonists have produced exacerbated OCD dysfunctional release of normally inhibited
symptoms, suggesting that OCD sufferers have a ªfixed-action patternsº (innate species-specific
heightened sensitivity to serotonergic stimula- responses). In this model it is assumed that the
tion (Tallis, 1995). Strengthening this finding is basal ganglia stores motor programs for action
the reversal of this effect by administration of which are innate, and that it forms a gating
serotonin receptor antagonists (Benkelfat et al., mechanism for their release. The basal ganglia
1990). Challenge study findings have not been detects stimuli which activate fixed-action
entirely consistent, however. In reviewing this patterns, and allows the release of these
evidence, Barr et al. (1993) conclude that behaviors which take the form of grooming
dysregulation of the serotonergic system is and safety rituals.
probable, but the nature of the dysregulation A variety of studies suggest that frontal lobe
is unclear. While neuroendocrine responses to activity in conjunction with the basal ganglia are
challenge suggest hyposensitivity, behavioral implicated in OCD. Neuropsychological assess-
findings suggest a hypersensitivity. In light of ments (see Tallis, 1995) and EEG studies are
these inconsistencies, a number of investigators suggestive of frontal lobe deficits (Rauch &
suggest a more complex model of OCD taking Jenike, 1993). PET studies have also suggested
into account multiple transmitter systems (Leck- some type of frontal-striatal abnormality. PET
man et al., 1995; Rauch & Jenike, 1993). studies and SPECT (single-photon-emission
computed tomography) studies have consis-
tently shown increased metabolic activity in the
6.17.6.5.2 Neuroanatomy of OCD
frontal cortex of OCD patients compared to
Anatomical models of OCD have focused on controls (Baxter et al., 1990; Cottraux et al.,
selected parts of the brain, specifically the basal 1996; Rauch & Jenike, 1993). More recent
ganglia, the frontal cortex, and the limbic studies have shown increased metabolic activity
structures connecting them. The basal ganglia to provocative stimulation among OCD patients
are a subcortical group of nuclei involved in the (Cottraux et al., 1996; Rauch et al., 1994) as well
regulation of movement, as well as cognitive as normal controls (Cottraux et al., 1996). Other
functioning (Crutcher, 1985). Three structures PET studies have found that elevated metabolic
in the basal ganglia make up the corpus activity is no longer present following successful
striatum: the caudate nucleus, putamen, and treatment with medication or behavior therapy
globus pallidus. It is the structure and activity of (Baxter et al., 1987, 1992). Evidence of hyper-
the corpus striatum which has been most closely metabolic activity in the orbitofrontal gyri and
associated with OCD. Computerized tomogra- the basal ganglia has led to theorizing that a
phy (CT) studies have found caudate volume to fronto-striatal dysfunction is at the core of OCD.
be smaller in OCD subjects than in controls Insel (1992) proposed that these regions make up
(Luxenburg et al., 1988). Positron emissions a cortical-striatal-thalamic-cortical circuit that
tomography (PET) scan studies have found is hyperactive. In this circuit the caudate nucleus
increased metabolic activity in the caudate sends inhibitory signals to the globus pallidus
nucleus of OCD patients during a resting state which then fails to inhibit the thalamus from
(Baxter et al., 1987, 1988). Other studies have sending signals to the cortex. The cortex thus
receives signals that it would not receive if the OCD symptoms are used to establish concor-
circuit were operating normally. Further inhibi- dance, the evidence is strong for a genetic factor
tion by the caudate nucleus prevents the circuit in OCD (Black, Noyes, Goldstein, & Blum,
from being interrupted, and therefore the 1992; Carey & Gottesman, 1981). The evidence
messages continue to reverberate. of concordance for other disorders, especially
Baxter et al. (1990, 1992) have proposed a anxiety disorders, has led some to conclude that
slightly different way in which this circuit may what is transmitted in families with OCD is a
be dysfunctional. The hyperactivity may result diathesis for anxiety disorders rather than
from faulty screening of sensory information. specifically for OCD (Black et al., 1992). Recent
The gating and screening activities of the interest has been generated by the hypothesis
striatum may not work properly and thereby that at least a subtype of OCD and Tourette's
fail to inhibit impulses/thoughts which ªleakº syndrome (TS) are different phenotypic expres-
into consciousness and are experienced as sions of a common underlying genotype (Pauls,
obsessions. Compulsions are fixed-action pat- 1990, 1992). As noted earlier, OCD occurs more
terns that occur automatically in response to often in TS patients and their family members,
this material and require effortful and conscious and TS occurs more often in OCD patients and
suppression and/or neutralization. This effort their family members (see Pauls, 1990). The
produces the hyperactivity in the basal ganglia evidence has led some to suggest that these
and frontal lobes observed in OCD patients. disorders share a common genetic underpinning
Other models have postulated a problem with (Leckman & Chittenden, 1990; Pauls, 1990).
the ªcomparator mechanismº in the limbic
system (Gray, 1984) or in the basal ganglia
(Pitman, 1989) which matches sensory informa- 6.17.6.6 Biological Treatments for OCD:
tion with what is anticipated. When a mismatch Medications and Psychosurgery
occurs, general arousal and corrective proce-
6.17.6.6.1 Medications
dures are undertaken. However, a defective
comparator mechanism might result in faulty Nearly three decades have passed since the
evaluation of sensory input (e.g., my hands feel late 1960s when the first reports of the potential
dirty when they are not), and ineffective efficacy of clomipramine (Anafranil) in the
corrective action (washing my hands to remove treatment of OCD (Stein, Spadaccini, & Hol-
dirt that is not there). Because of a faulty lander, 1995). Since that time a number of more
comparator, the dirt can only be felt and not selective SRIs have been developed and in-
removed. vestigated as treatments for OCD, including
While evidence is strong for some form of fluvoxamine (Luvox), fluoxetine (Prozac), and
frontal-striatal circuit involvement as a neuro- sertraline (Zoloft). A substantial number of
logical substrate of OCD, the etiological clinical and placebo-controlled trials have now
significance of this circuit is unclear. It may been conducted with these medications. Quali-
simply be the biological expression of the tative reviews of the treatment outcome litera-
disorder and not the cause of it. There is some ture (Jenike, 1990; Rasmussen, Eisen, & Pato,
evidence that hyperactivity in the frontal lobes 1993; Steketee, 1993), as well as quantitative
can be produced in normal subjects by proces- (meta-analytic) studies (Greist, Jefferson, Ko-
sing obsessional material (Cottraux et al., 1996). bak, Katzelnick, & Serlin, 1995; Piccinelli, Pini,
Nonetheless, the substantial evidence for bio- Bellantuono, & Wilkinson, 1995; Stein et al.,
logical substrates associated with OCD will 1995), provide a useful overview of the effec-
undoubtedly foster considerable further re- tiveness of the serotonin transport inhibitors.
search to clarify the mechanisms and roles of Based on double-blind, placebo-controlled
the various biochemical substances and neu- studies, these reviews conclude that all of these
roanatomical structures. SRIs are effective in the treatment of OCD with
at least a moderate improvement occurring in
from 55±70% of previously untreated patients
6.17.6.5.3 Genetics
(Rasmussen, Eisen, & Pato, 1993; Steketee,
The findings from twin and family studies 1993). The average effect sizes from meta-
have suggested some degree of genetic influence analytic studies range as high as 1.48±1.64
in OCD (for reviews see Kolada et al., 1994; (Greist et al., 1995; Stein et al., 1995). Table 1
Pauls, 1990, 1992; Rasmussen, 1993), but these presents findings for medication studies using
studies have not always been consistent or the YBOCS as an outcome measure.
without problems. When diagnosis of OCD is Although early studies with clomipramine
used to define concordance, the evidence for suggested that its antidepressant effect was
genetic transmission is weak or inconsistent responsible for at least some benefit in OCD
(Kolada et al., 1994). However, when subclinical symptoms (Marks, Stern, Mawson, Cobb, &
McDonald, 1980), more recent studies indicate tions which may make the treatment less
that SRIs work for OCD patients whether or effective (Clomipramine Collaborative Study
not they are depressed. Comparisons of SRIs Group, 1991). For CMI the side effects are
with other non-SRI drugs have all favored the mainly anticholinergic. There is a slight chance
SRIs in the treatment of OCD (Jenike, 1993). A of seizures, especially at higher dosages
newer SRI, paroxetine (Paxil) has also shown (DeVeaugh-Geiss, Landau, & Katz, 1989) and
promise in recent studies (Kaye & Dancu, 1994). partial or total anorgasmia is common (Mon-
Very few studies directly compare the effec- teiro, Noshirvani, Marks, & Lelliott, 1987).
tiveness of SRIs to each other. Comparisons of Although many patients may be willing to
the efficacy of CMI versus fluoxetine have failed tolerate the anorgasmia for the symptom relief
to find differences (Freeman, Trimble, Deakin, provided by CMI, it is a major cause of
Stokes, & Ashford, 1994; Pigott et al., 1990). treatment dropout (Rasmussen et al.). For
However, a meta-analytic comparison found fluoxetine, up to 50% of patients reported side
CMI effect sizes (1.53 to 1.84) to be larger than effects including fatigue, nausea, insomnia,
those for fluoxetine (1.34) (Jenike, Baer, & tremor, and sexual dysfunction (Jenike, 1990).
Greist, 1990). Other meta-analytic studies have Similar side effects have been reported for
tended to show a similar preference for CMI fluvoxamine (Jenike, 1990), although in direct
(Greist et al, 1995; Stein et al., 1995), although at comparison, CMI had more anticholinergic side
least one such study has been equivocal on this effects and more sexual dysfunction while
issue (Piccinelli et al., 1995). (See also Table 1.) fluvoxamine-treated patients reported more
Despite these indications that CMI is more headaches and insomnia (Freeman, Trimble,
effective than the other SRIs, more large-scale Deakin, Stokes, & Ashford, 1994). In a
direct comparisons of treatment efficacy are comparison of the side effects of CMI and
needed before drawing definitive conclusions fluoxetine, Jenike et al. (1991) found that only
regarding the differential effectiveness of these 3% of patients had no side effects from CMI
drugs. There are several reports which suggest while 43% had no side effects on fluoxetine.
the method of administration of SRIs may Other problems associated with use of
influence their efficacy. In several clinical series, medications include dropout, relapse on or off
intravenously administered CMI worked sig- medication, and inadequate response. Dropout
nificantly faster than oral methods (Sallee, or noncompliance rates for SRIs have not been
Pollock, Perel, Ryan, & Stiller, 1989; Koran, well studied. Recent reports range from 10
Faravelli, & Pallanti, 1994) and, of particular (Tollefson, et al. 1994) to 26% (Freeman et al.,
importance, IV administration was effective for 1994). Most studies provide insufficient infor-
treatment of refractory patients (Fallon et al., mation to determine dropout rates. In a
1992). comparison of four large clinical trials, Greist
While the effectiveness of SRIs in the et al. (1995) reported significantly fewer drop-
treatment of OCD has been established, it outs for CMI (12.5%) than for other SRIs
should be noted that the response to these (23±27%). Little information exists on relapse
medications is not usually a complete cessation rates following cessation of SRI treatment.
of symptoms. In fact, Jenike (1990) estimates Pato, Zohar-Kadouch, Zohar, and Murphy
that patients treated with SRIs show only a (1988) found a nearly 90% relapse rate within
30±60% reduction in their symptoms, and 30% seven weeks of discontinuation of CMI.
or more show no improvement at all (Rasmus- Furthermore, the length of treatment was not
sen et al., 1993). Furthermore, most patients related to relapse. Likewise Leonard et al. (1991)
remain ªchronically symptomatic.º There is no found an 89% relapse rate when desipramine
question that the medications improve the was substituted for CMI. In two reports on
symptom picture for patients with OCD, but relapse during continued medication treatment,
the SRIs do not represent an ideal solution in the Leonard et al. found an 18% relapse rate two
treatment of OCD. months after successful CMI treatment, and
Although the tolerableness of the side effects Fontaine and Chouinard (1989) found a 23%
of SRIs is generally better than that of tricyclic relapse rate after one year on fluoxetine.
antidepressants (Montgomery & Kasper, 1995), As noted earlier, a substantial number of OCD
it is still of some concern in OCD. Major side patients do not respond or respond marginally to
effects include sedation, sexual dysfunction, and SRI treatment. Although it is not clear who will
weight changes (Rasmussen et al., 1993). Other not respond favorably to SRIs, there are several
side effects vary somewhat as a function of the suggestions in the literature. In Ackerman,
specific medication. Rasmussen et al. conclude Greenland, Bystritsky, Morgensterns, and
that CMI has the most problematic side effects Katz's (1994) review of predictors from a multi-
profile. These side effects may compromise center clinical trial of over 500 patients, the only
patient compliance or necessitate dosage reduc- predictor of treatment response was age of onset.
Patients who develop OCD later in life showed a for OCD: combinations did not usually improve
significantly better response to SRIs, a finding upon either treatment administered alone.
contrary to that for behavioral treatment where Likewise, behavioral treatments have also been
early onset is associated with better outcome combined with pharmacological ones, although
(Foa et al., 1983). Additionally, patients with to date surprisingly few studies have undertaken
comorbid schizotypal personality disorder do controlled comparisons of these combinations.
not appear to respond well to SRI treatment Two studies by Marks and colleagues compared
(Jenike, 1990). Augmenting SRI treatment for clomipramine to placebo, and behavioral
patients who show an inadequate response has treatment to relaxation (Marks et al., 1980)
been the subject of some research. Evidence and to antiexposure instructions (Marks et al.,
suggests that patients with comorbid tic dis- 1988). In the first study, CMI improved mood
orders or schizotypal personality who are and OCD symptoms and behavior therapy led
treatment resistant to SRIs may respond to to additional improvement on most OCD
the addition of neuroleptics (e.g., Goodman, symptoms, but not on mood. Combined
McDougle, Barr, Aranson, & Price, 1993; clomipramine plus exposure therapy was only
McDougle, Goodman, Leckman, & Price, slightly better than drug alone at 10 weeks. After
1993). two years (Mawson, Marks, & Ramm, 1982)
and six years (O'Sullivan, Noshirvani, Marks,
6.17.6.6.2 Psychosurgery Monteiro, & Lelliott, 1991), improvement in
OCD symptoms generally continued. At the
For patients who do not respond to multiple
latter follow-up, most patients (61%) reported
medication trials or behavior therapy, psycho-
taking medication, but only 25% had continued
surgery may be an option. The development of
on clomipramine. After six years, the original
stereotactic techniques appears to have resulted
CMI-treated group improved more than the
in more precise lesion placement, increasing the
placebo group on only one of 16 measures. In
safety of psychosurgery techniques and redu-
Marks et al.'s second study (1988), CMI initially
cing their side effects. Four types of psycho-
enhanced the effect of exposure but this
surgery are currently used for treatment of
disappeared with continued exposure treatment
OCD: cingulotomy, capsulotomy, limbic leu-
and was not evident at follow-up. In both
cotomy, and subcaudate tractotomy (Mindus &
Marks et al. studies (1980, 1988) greater average
Jenike, 1992). No controlled trials of the
improvement occurred with exposure compared
effectiveness of psychosurgery have been con-
to CMI, and in the later study 75±80% of
ducted on the uncontrolled studies; improve-
patients improved with ERP compared to
ment rates between 25 and 100% have been
22±33% for CMI. Combined treatment led to
reported (Chiocca & Martuza, 1990; Jenike
more subjects who were ªmuch improvedº after
et al., 1991; Baer et al., 1995). These improve-
one year (73% vs. 50% for exposure alone), but
ment rates should be viewed with caution since
not to more average improvement.
most are based on early studies before current
A third study compared fluvoxamine to this
behavioral and medication treatments were
medication plus exposure and to placebo plus
adequately developed. Whether such high rates
exposure (Cottraux et al., 1989). Behavior
of improvement will be observed among
therapy had a poorer showing compared to
patients who have failed to respond to multiple
other studies (see above). All three groups
medication trials and behavior therapy remains
improved, with only a slight advantage for
to be seen. At least one recent study (Baer et al.)
combined drug and behavioral treatment at six
reported a 45% improvement rate (substantially
months. In contrast to the studies by Marks
improved plus partial treatment responders)
et al., fluvoxamine led to more average
following cingulotomy for patients who had
improvement than exposure and produced
adequate but unsuccessful presurgery treat-
more successes (54% vs. 40%) at post-test
ments. Following a thorough review of the
(Cottraux et al.). However, one year later, mean
available evidence on effectiveness and side
improvement was nearly equivalent across
effects, Chiocca and Martuza (1990) recom-
treatments and slightly more exposure patients
mend cingulotomy as the first procedure, based
were improved (50% vs. 45%). The combina-
primarily on the low rate of complications
tion treatment showed some potentiating effect
following this surgery.
at six months, but this was minimal after a year.
With only three studies conducting a head-to-
6.17.6.7 Combined Interventions for Treatment head comparison of ERP and SRI or SSRI
of OCD medications, there is clearly inadequate evi-
dence to judge whether combined treatment
We have already discussed the effects of offers advantages or whether either treatment
combined cognitive and behavioral treatments alone is the best choice for particular patient
groups. Recent research by Foa, Liebowitz and insight or even whether insight influences
colleagues (Foa et al., 1993) suggests that ERP is treatment response. The similarities of some
more effective than clomipramine and more diagnoses to OCD (e.g., bulimia, hypochon-
effective than the combination. However, con- driasis) argue for possible underlying pathol-
clusions are premature since this study has not ogy, but to date research has only hinted at some
yet been completed and study inclusion criteria shared characteristics (e.g., biological traits,
were stringent, reducing generalizability of treatment response). In view of the increasingly
findings for clinical OCD patients. common use of the term ªOC Spectrumº
Meta-analysis of ERP and SRI-medication conditions that include impulsive disorders
effects provide some information pertinent to (e.g., gambling, trichotillomania), determina-
this issue. In 1987, Christensen and colleagues tion of the exact relationship, if any, of these
concluded that behavioral and pharmacological conditions to OCD is needed before the field
interventions were equivalent in efficacy, becomes attached to conceptual views and
though they acknowledged that their metho- treatment tactics that may be inaccurate.
dology may have overestimated medication Some findings suggest that there may be
effects (Christensen, Hadzi-Pavlovic, Andrews, subtypes of OCD. For example, one subgroup
& Mattick, 1987). A more recent meta-analysis appears to be early-onset males with tics and/or
by van Balkom et al. (1994) concluded that both schizotypal traits and poor insight, who are
ERP alone and ERP plus medications was more refractory to common treatment packages such
effective than SRIs on self-rated measures. as SRIs and ERP. It is important to determine
However, they found no differences when whether patients with particular combinations
assessor-rated measures were used. A recent of OCD characteristics or comorbidity benefit
review of findings concurred with van Balkom more from specialized combinations of treat-
and others that the lack of equivalent measurements (e.g., addition of neuroleptics, social skills
ment instruments makes the task of comparing training, or change in living situation). Corre-
these treatments and their combinations very spondingly, in view of cultural similarities and
difficult and equivocal at best (Stanley & differences in OCD symptom pictures, should
Turner, 1995). With the general adoption of modifications be made to psychosocial treat-
the Yale±Brown Obsessive Compulsive Scale ments to accommodate cultural context, and if
(YBOCS, Goodman et al., 1989), it appears that so how? For example, Williams, Chambless,
this problem is being addressed. Table 1 and Steketee (1996) have suggested some
includes several pharmacological, behavioral, modifications to ERP for African-American
and cognitive studies that employed the YBOCS patients who showed specialized treatment
to assess outcome. A visual comparison of response patterns. Along the same vein, before
findings shows substantial reductions using we proceed too far with inclusion of significant
medications, with post-test scores generally others in the treatment process, it is important
ranging from 14 to 19. Unfortunately, few to understand how these individuals influence
studies included follow-up results, but these patients' symptoms before and during therapy.
were positive in two studies so long as It may be that for some patients, including
medications were continued. Post-test scores family members in therapy is detrimental rather
for ERP treatments (and the single cognitive than helpful, whereas for others, family in-
therapy) ranged from 9 to 17 with consistently volvement may be essential to recovery.
stable gains at follow-up. These studies show a Two areas engendering intensive research in
range of outcomes, with somewhat more recent years are, first, biological underpinnings
average benefits for the behavioral methods. of OCD and corresponding pharmacological
treatments; and second, cognitive traits and
theoretical models, and cognitive psychother-
6.17.7 FUTURE DIRECTIONS apy. With the availability of more precise
capabilities to physically examine chemical
In the above review, we have discussed a and structural mechanisms, researchers have
variety of areas of clinical research regarding the intensified their search for essential factors
psychopathology and treatment of OCD. involved in the pathogenesis of this disorder.
Although much is now understood about this Efforts to identify effective biological treat-
disorder, there remain significant areas in need ments have also progressed rapidly, although
of further investigation. For example, the level these two areas of research are not always
of insight into obsessions varies across sub- closely connected. Baxter and colleagues' (1992)
clinical and clinical populations, and even case reports of neurochemical changes follow-
within subjects depending on the mood state ing effective drug and behavioral therapy are
or context, but it is not clear whether some extremely interesting but require replications in
treatments (e.g., cognitive therapies) can change controlled trials from other centers. Likewise,
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6.18
Panic Disorder and Agoraphobia
PAUL M. SALKOVSKIS

6.18.2 DEVELOPMENT OF THE PANIC CONCEPT 401
6.18.2.1 Lay and Psychiatric Conceptualizations 401
6.18.2.2 The Development of Psychological Conceptualizations of Panic 402
6.18.3 PREVALENCE OF PANIC 403
6.18.3.1 Panic Attacks in Nonclinical Populations (ªNonclinical Panicº) 403
6.18.3.2 Panic Disorder 404
6.18.3.3 Correlates of Panic Disorder 404
6.18.3.4 Comorbidity 404
6.18.3.5 Natural History of Panic 405
6.18.3.6 Other Issues 405
6.18.4 THEORIES OF PANIC 406
6.18.4.1 The Original Biological Hypothesis: Klein's View 406
6.18.4.2 The Neuroanatomical Hypothesis 408
6.18.4.3 Neurochemical Hypotheses: Noradrenaline and the Locus Coeruleus 410
6.18.4.4 Physiological Accounts of Panic: Panic as a ªHyperventilation Syndromeº 410
6.18.4.4.1 Evidence for an association between panic and hyperventilation 411
6.18.4.4.2 Hyperventilation as a CAUSE or EFFECT of panic 412
6.18.5 PSYCHOLOGICAL THEORIES OF PANIC 413
6.18.5.1 Barlow's Model: False Alarms and Learned Alarms 413
6.18.5.2 The Cognitive Hypothesis of Panic 414
6.18.5.3 The Importance of the Idiosyncratic Nature of Catastrophic Misinterpretations 415
6.18.5.3.1 Panic, cognitions, and avoidance 416
6.18.5.4 Agoraphobia 418
6.18.5.4.1 Correlates of agoraphobia 419
6.18.5.5 The Cognitive Account and Research into Panic 420
6.18.5.6 The Relevance of Psychobiological Factors to the Cognitive Hypothesis of Panic 421
6.18.5.6.1 The cognitive link between panic and hyperventilation-induced symptoms 421
6.18.6 EVALUATING THE COGNITIVE HYPOTHESIS 423
6.18.7 TREATMENT 425
6.18.7.1 The Theoretical Roots of Treatment 425
6.18.7.1.1 Cognitive therapy for panic: some general issues 427
6.18.7.1.2 Clinical implementation of cognitive-behavioral therapy 427
6.18.7.1.3 Effectiveness of cognitive-behavioral therapy 430
399
400 Panic Disorder and Agoraphobia
6.18.1 INTRODUCTION Although panic attacks have been recognised

since the nineteenth century (albeit in various
Panic attacks are characterized by sudden forms and with a range of descriptive labels),
and apparently inexplicable increases in anxiety the importance of panic attacks was only
accompanied by a range of intense bodily formally recognised on the introduction of the
sensations. Over the last two decades, clinical third edition of the Diagnostic and statistical
problems characterized by recurrent panic manual of mental disorders (DSM-III) of the
attacks have become a major focus of biological American Psychiatric Association (American
and psychological research into anxiety. Prob- Psychiatric Association, 1980). In DSM-III, the
ably the main reason for this upsurge in interest presence of relatively frequent panic attacks,
in panic was the nearly simultaneous develop- some of which were spontaneous (i.e., uncued
ment of effective psychological and biological and unexpected) was defined as pathognomo-
treatments for a range of anxiety disorders, nic of two conditions in the anxiety disorders
coupled with the growing awareness of the grouping; Panic Disorder and Agoraphobia
relevance of panic attacks to treatment outcome with Panic.
(Rachman, 1990). The DSM description of panic (currently in
The strong association between panic attacks the form of DSM-IV) has become the
and avoidance behavior, particularly in agor- standard way of operationally defining panic
aphobia, has led many writers to the conclusion attacks and Panic Disorder, with and without
that panic attacks are the principal cause of agoraphobia. Table 1 gives the DSM-IV
agoraphobia (Barlow, 1988; Klein, Ross, & criteria for panic. There are a number of
Cohen, 1987; Rachman, 1990; Thyer, 1986; shortcomings of this definition. Perhaps the
Thyer & Himle, 1985). Even when not accom- most important of these concerns the defini-
panied by agoraphobic avoidance, panic attacks tion of panic frequency; it is possible to
are associated with considerable distress as well obtain a diagnosis of Panic Disorder as a
as social and occupational handicap (i.e., in result of a single panic attack followed by a
Panic Disorder). The importance of the phe- period of at least one month's apprehension
nomenon of panic goes beyond these condi- of having another. This definition could have
tions, however; it has been demonstrated that the result that some control subjects in
panic attacks are prevalent in all other anxiety investigations into panic may experience more
disorders (Barlow et al., 1985). A number of frequent panic attacks than some patients in
studies have also shown that panic also occurs the Panic Disorder groups. The obvious
relatively frequently in nonclinical subjects solution (and the one employed by many
(Margraf & Ehlers, 1988; Norton, Dorward, research groups) is to supplement DSM-IV
& Cox, 1986; Norton, Harrison, Hauch, & definitions of Panic Disorder with the re-
Rhodes, 1985), and that subjects with infre- quirement that panic subjects should be
quent (nonclinical) panic share many of the currently experiencing panic attacks at a
characteristics of patients diagnosed as suffer- predefined frequency.
ing from Panic Disorders. Such observations As is clear from the criteria in Table 1 that
have led to the suggestion that infrequent panic the strong association between panic attacks
represents the nonclinical end of an agorapho- and avoidance behavior, particularly in agor-
bic continuum (Rachman, 1990), challenging aphobia, has led many writers to the conclu-
earlier suggestions that agoraphobia is discon- sion that panic attacks are the principal cause
tinuous from normal fear (Arrindell, 1980; of agoraphobia (Barlow, 1988; Klein et al.,
Roth, 1959). 1987; Rachman, 1990; Thyer, 1986; Thyer &
Current psychological thinking tends to Himle, 1985). Even when the diagnosis is of
assume that panic and agoraphobic avoidance agoraphobia without a history of panic
may have a common basis in psychological attacks this depends on the ªpresence of
factors which are normally distributed in the agoraphobia related to fear of developing
general population, and that anxious patients panic-like symptoms (e.g., dizziness or diar-
are people who are especially vulnerable to rhea).º Although it is recognized here that
the development of specific anxiety disorders panic and panic-like symptoms are important
as a result of being at the extreme end of for (and often central to) the experience of a
such a continuum or several continua. The substantial proportion of agoraphobics, the
basis of the putative underlying dimensions attribution of all agoraphobia to panic and
seems likely to be cognitive (McNally, 1990, panic-related symptoms may be premature
1994; Rachman, 1990; the psychological basis (Salkovskis & Hackmann, 1997). Nevertheless,
of dimensional approaches to panic is the last two decades has seen the concept of
discussed in greater detail in Salkovskis, agoraphobia fade and become subsidiary to
1988a). panic.
Development of the Panic Concept 401
Table 1 Criteria for panic disorder with and without agoraphobia.
For a diagnosis of Panic Disorder, at least two unexpected attacks must occur, characterized by at least four of
the symptoms listed below
Also requires:
Recurrent and unexpected panic attacks and at least one of the attacks is followed by at least one month of
persistent concern about having additional attacks, or worry about the implications of the attack or its
consequences (such as losing control or having a heart attack) or a significant change in behavior related to
the attacks
Panic must also be unexpected, i.e., did not occur immediately before or on exposure to a situation that almost
always caused anziety, or produced by another disorder (social phobia, obsessive-compulsive disorder, post-
traumatic stress disorder, or separation anxiety disorder)
Symptoms (criteria specify an increase in at least four in at least one attack)
Physical
Shortness of breath numbness or tingling sensations
Choking depersonalization or derealization
Palpitations or tachycardia flushes or chills
Chest pain or discomfort trembling or shaking
Sweating feeling dizzy, lightheaded, unsteady, faint
Nausea or abdominal distress
Mental
Fear of dying fear of losing control or going crazy
Other characteristics
At least four or more symptoms developed abruptly and reached a peak within 10 minutes of the beginning of
the first symptom noticed
Can be associated with avoidance behavior (especially agoraphobia and anticipatory anxiety)
Onset can be associated with physical disorder or factors; diagnosis depends on the persistence beyond the
cessation of precipitating organic factors (e.g., Hyperthyroidism, caffeine intoxication, etc.)
Painc Disorder with Agoraphobia: as above, but in addition
Anxiety about being in places or situations from which escape might be difficult (or embarassing) or in which
help may not be available in the event of having an unexpected or situationally predisposed panic attack or
panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include
being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus
or train. The situations are avoided or endured with marked distress or with anziety about having a panic
attack or panic-like symptoms, or require the presence of a companion
6.18.2 DEVELOPMENT OF THE PANIC responses to extraneous stimuli and situations,

CONCEPT such as the effects of apparent reverses during
battle or of sudden noises. More ªscientificº
6.18.2.1 Lay and Psychiatric
descriptions of anxiety began to appear during
Conceptualizations
the nineteenth century (notably those of Charles
The term ªpanicº is said to be derived from Darwin and William James), although these do
the Greek to panikon deima, which was a not appear to have been related to panic as such.
description of the effects on lone travelers of Modern writers have suggested that early
sudden noises made by the God Pan (Baker, descriptions of a range of syndromes (such as
1989). There are a number of literary allusions neurasthenia, effort syndrome, etc.) may have
to panic from Classical Greek times onwards. been descriptions of Panic Disorder (Skerrit,
Most descriptions seem to concern identifiable 1983). While this is possible, such attempts to
pinpoint early descriptions of Panic Disorder time, Pitts and McClure (1967) demonstrated
tend to be overinclusive. For example, careful that anxiety attacks could be precipitated by
examination of early and late descriptions of intravenous infusions of the alkaline substance,
ªNeurastheniaº (e.g. Beard, 1869; Cohen & sodium lactate. Later work showed that this
White, 1951) indicate a quite different pattern of effect was specific to patients with Panic
symptoms, probably including characteristic Disorder as opposed to other anxiety disorders
subgroups of anxious and depressed patients (Klein, 1981), and that prior administration of
whose main complaint was weakness on imipramine blocked the response to lactate
exercise, often more closely resembling modern (Rifkin, Klein, Dillon, & Levitt, 1981). Taken
accounts of Chronic Fatigue Syndrome. That together, this data was believed to indicate that
there may have been overlaps with modern panic attacks were the core manifestation of a
diagnoses is not impossible, but the presence of specific biological dysfunction and that psy-
these type of accounts cannot be taken as chological aspects such as agoraphobic avoid-
evidence of the ubiquity of the diagnosis of ance were entirely secondary (Klein, 1980; Klein
Panic Disorder. et al., 1987; Sheehan, 1982). This view on the
More relevant are explicitly psychiatric primacy of panic attacks was in sharp contrast
accounts of anxiety problems such as that of to Freudian conceptualizations current in the
Westphal (1872), who identified a specific 1970s, in which panic was regarded as a
constellation of symptoms which were char- secondary phenomenon, with free-floating an-
acteristic of what we now recognize as panic xiety (unfocused anxiety arising from subcon-
associated with Agoraphobia. It fell to Freud scious conflicts) being the supposed origin of
(1894, 1895) to specifically identify episodic and panic.
ªanxiety attacksº (Angstanfaelle) which were An important corollary of Klein's biological
not triggered by specific situations and tended hypothesis was that panic anxiety unlike
to be unexpected; he described such episodes as anticipatory or phobic anxiety was, by virtue
being important symptoms in defining ªanxiety of its endogenous nature, unaffected by psycho-
neurosis.º Anxiety neurosis was said to be logical influences. This assertion extended to
characterized by acute dread and fear of death, statements concerning the ineffectiveness of
night terrors, phobias, vertigo, parasthesias, psychological treatments, including exposure
hypervigilance, excessive arousal, and anxious (Zitrin, Klein, & Woerner, 1980). Klein's view
expectation (Lewis, 1967). Freud defined anxi- was the basis for the definition adopted by
ety attacks, which were often preceded by DSM-III (American Psychiatric Association,
periods of generally heightened anxiety, as 1980) and its modification, DSM-III-R (Amer-
suddenly breaking through and being accom- ican Psychiatric Association, 1987). Not sur-
panied by a range of physical sensations similar prisingly, psychological theorists and
to those recognized today by the DSM-III-R practitioners began to challenge the primacy
definition. Anxiety attacks continued to be of endogenous and biological factors in panic
intermittently described by psychiatric writers and its treatment.
such as Diethelm and Fenichel, but invariably
as a symptom of underlying anxiety (Baker,
1989) rather than as defining features. 6.18.2.2 The Development of Psychological
The 1960s were marked by an increased Conceptualizations of Panic
prominence afforded to panic attacks, with the
importance of the concept of panic being With the early interest in panic arising from
championed by Klein (1964), who described biological findings, those involved in psycho-
what he believed to be the specific responsive- logical conceptualization were slow to acknowl-
ness of anxiety characterized by panic to edge the diagnostic importance of panic, and
imipramine but not to phenothiazines (this some still dispute the value of the label (Marks,
work is often wrongly described as being a 1987a, 1987b). Perhaps the most influential
comparison of imipramine compared with early psychological account of the nature of
benzodiazepines, based on the use of the term panic attacks was that of Lader and Mathews
ªtranquilizersº). Subsequently, this ªpharma- (1968,1970). Drawing on their previous theoriz-
cological dissectionº was extended to show that ing concerning the tendency of arousal to inhibit
benzodiazepines benefited those with general- habituation, and, in more extreme instances, to
ized and phobic anticipatory anxiety but not result in sensitization, they postulated that
those with panic (Zitrin, 1983; Zitrin, Woerner, panic attacks were the consequence of an
& Klein, 1981). Others enthusiastically took up inhibitory function which occurred if the
the view that panic attacks were a distinct arousal/sensitization process proceeded too
marker of a different, possibly endogenous type far. Thus, the function of panic attacks was
of anxiety (e.g., Snaith 1968). At about the same said to be to dampen down physiological
Prevalence of Panic 403
responses in an ªover excitedº system. Although Eaton, & Keyl, 1985; Wittchen, 1986). Other
this hypothesis did not receive support from investigations have been carried out into the
subsequent research, it was influential because it prevalence of panic attacks per se (Margraf &
introduced the idea of the interaction between Ehlers, 1988; Norton et al., 1986; Norton et al.,
psychological and physiological factors in 1985). Taken together, these studies are com-
panic. Aspects of this view can be found in prehensive and representative enough to allow
Barlow's hypothesis concerning the role of some confidence in current estimates of pre-
background stress (Barlow, 1988). valence and demographic factors.
The later emphasis on cognitive conceptuali- Bebbington (personal communication) de-
zations resulted in a number of psychological scribed epidemiological studies as being an
hypotheses intended to account for panic attacks exercise in ªcounting swans on the lawn.º There
occurring in association with agoraphobia, is some value in doing so, but the exercise does
based on the notion that panic was the result not necessarily give accurate information as to
of ªfear of fear.º The most important advocates how the swans got there and what might happen
of this position are Goldstein and Chambless to them subsequently. Instead, the preoccupa-
(1978), Chambless and Goldstein (1980), tion tends to be with deciding whether swans are
Chambless and Gracely (1989), and Weekes truly present or whether they may be particularly
(1977). The fear of fear hypothesis is based on the attractive ducks. In panic, as in most areas, there
idea of an ascending spiral in which the patient are few longitudinal studies which might help
who enters or anticipates confronting an anxiety provide more definitive clarifications of issues of
provoking situation becomes afraid of the mechanism. Cross-sectional studies cannot pro-
possibility of experiencing fear (e.g., Foa, vide unambiguous information in this respect, as
Steketee, & Young, 1984). Clark (1988) has they are vulnerable to cohort effects, in which
pointed out that earlier versions of the fear of changes in prevalence and comorbidity in
fear hypothesis tend to over predict the different age groups reflect samples subject to
occurrence of the panic spiral; in panic prone variations in critical influences and naturally
subjects, any occurrence of anxiety should result occurring selection processes.
in panic. Later versions of this hypothesis
propose that fear of the consequences of anxiety
and panic may also play an important part (e.g., 6.18.3.1 Panic Attacks in Nonclinical
Chambless & Gracely, 1989). With later mod- Populations (ªNonclinical Panicº)
ifications, the fear of fear view closely resembles
the cognitive hypothesis of panic discussed Norton et al. (1985) found that, as measured
below. These modifications concern reconcep- by questionnaire, 34.5% of 186 students
tualizing fear of fear to fear of the consequences screened had experienced a panic attack in
of fear (e.g., patients may fear that anxiety will the preceding year, and that 2.2% had experi-
put a dangerous strain on their heart). enced at least three such attacks in the preceding
two weeks. In a second questionnaire study with
some methodological refinements, Norton et al.
6.18.3 PREVALENCE OF PANIC (1986) obtained figures of 35.9% and 3.1% for
the same criteria as in the earlier study, this time
The importance of the phenomenon of panic is among a sample of 256 students. Margraf and
highlighted by epidemiological findings that not Ehlers (1988) conducted two studies intended to
only is Panic Disorder per se very common, but replicate the findings from Norton's group in a
also that a considerable proportion of non- German sample, to determine the validity and
clinical subjects surveyed experience panic reliability of the questionnaire method as
attacks, and that panic attacks frequently co- compared to structured clinical interview meth-
exist with a range of other disorders, especially odology, and to evaluate the response of
(but not exclusively) other anxiety disorders. In nonclinical panickers to laboratory procedures.
considering the prevalence of panic, it is Margraf and Ehlers were able to replicate the
important to distinguish between the prevalence questionnaire results in both of their studies,
of occasional panic attacks (often described as obtaining higher rates for the year prevalence of
nonclinical panic when noted in the general panic (46% and 59%) and similar rates for three
population) as opposed to Panic Disorder, which panic attacks in three weeks (2% and 1%).
is an operationally defined diagnosis in DSM- However, analysis of agreement between ques-
IV; see below). A number of large-scale studies tionnaire and interview data indicated that the
have been carried out on the prevalence of Panic questionnaire tended to be systematically over-
Disorder with and without agoraphobia (Bour- inclusive, and that many (approximately 50%)
don et al., 1988, Myers, Weissman, Tischler, et of those identified by the questionnaire as
al., 1984; von Korff, Eaton, 1989; von Korff, panickers had a milder, subthreshold variant of
the problem as assessed by interview. The this finding might indicate that panic attacks
differentiation of nonclinical panic vs. Panic represent a precursor to the full disorder. Onset
Disorder presents a number of problems of of Panic Disorder is associated with negative life
definition and comparability; nevertheless, as a events such as marital conflict and bereavement
paradigm for the investigation of the processes (Pollard, Pollard, & Corn, 1989).
involved in panic attacks, it seems particularly Boyd (1986) analyzed ECA data across a
promising, especially if there is a psychological range of diagnoses, and found that people with
dimension underpinning both infrequent panic Panic Disorder were more likely to seek help for
in normal subjects and frequent panic in Panic their problem than those with any other
Disorder as proposed above. That is, the former psychiatric diagnoses (including schizophrenia).
may be a milder version of the processes The high prevalence of panic, both in other
involved in the latter. In studies carried out anxiety disorders and in affective disorders as
by both the German group and the Norton noted by Barlow (1988), Barlow and Craske,
group, it has been found that the characteristics (1988), and Barlow et al. (1985), has been
of the nonclinical panickers were similar to proposed as a factor influencing the decision of
those identified in clinical samples with respect these other groups to seek professional help
to the response to procedures such as lactate (Barlow, 1988). Boyd (1986) suggests that the
infusions and scores on questionnaire measures strong element of somatic sensations and fears of
of cognition and avoidance, and so on. associated catastrophes might account for
consultation. Work by Katon (Katon, 1984;
Katon, Vitaliano, Russo, Jones, & Anderson,
6.18.3.2 Panic Disorder 1987) provides some support for this view. He
noted that early presentation of panic to primary
The largest and most influential studies are
care physicians focused almost exclusively on
those carried out as part of the Epidemiologic
somatic symptoms (Katon et al., 1987), and that
Catchment Area (ECA) surveys, carried out in
physical causes were initially attributed in 89%
five centers in the USA. Area probability
of a sample of panic cases; misdiagnoses
samples (i.e., samples intended to be represen-
persisted ªfor months or even yearsº (although
tative of the characteristics of the populations as
exact figures are not given).
a whole) of 3000 people were selected at each site
The association between somatic diagnoses
(i.e., a total of 15 000 people). Response rates of
and panic is well known, particularly in the
75±80% were obtained; subjects were inter-
cardiac clinic (Skerrit, 1983; Waxler, Kimbiris,
viewed using an instrument called the Diag-
& Dreifus, 1971). The involvement of chest
nostic Interview Schedule (Eaton, Holtzer, von
physicians in this area has led to a search for
Korff et al., 1984). Different levels of definition
pathophysiological correlates of chest pain and
were employed; the simplest, six-month pre-
other cardiac symptoms; most commonly, this
valence of panic, provided figures consistent
has focused on the role of hyperventilation, with
with Margraf and Ehlers's (1988) nonclinical
a diagnosis of ªhyperventilation syndromeº
panic findings (28.5±31.1%; von Korff &
frequently being advocated (e.g. Lum, 1976;
Eaton, 1989). Panic Disorder prevalence rates
Magarian, 1982). This is discussed in greater
were higher than those previously (6.3±10.0% in
detail below.
the ECA study compared to Weissman's figures
of 3.3±6.8%) (Weissman, Leaf, Blazer, Boyd, &
Florio, 1986). It is possible that the discrepancy
may arise from the use of lay interviewers in the 6.18.3.4 Comorbidity
ECA study. Nevertheless, epidemiological stu-
The coexistence of panic with a wide range of
dies are consistent in placing the prevalence of
other psychiatric diagnoses has been noted,
Panic Disorder in the general population at
particularly by Barlow (Barlow & Craske, 1988;
around 5%.
Barlow et al., 1985). Panic attacks occur in
between 83% and 100% of patients with anxiety
6.18.3.3 Correlates of Panic Disorder disorders and in those with depressive disorders;
the lowest figure tending to be for Generalized
As noted above, the factors found to be Anxiety Disorder (Barlow & Craske, 1988).
associated with Panic Disorder also tend to be Strict DSM-III diagnoses of Panic Disorder
found in nonclinical panickers. Panic Disorder range from rates of 30±50% in major depression
is more common among women (75% of (Leckman, Weissman, Merikangas, Pauls, &
sufferers). Panic attacks are most likely to Prusoff, 1983; Vermilyea, 1987, cited in Barlow,
develop in the age range 18±24 years, while 1988) to 83% in anxiety disorders (Barlow et al.,
Panic Disorder is most likely to peak in the age 1985). There were few differences between the
range 24±44 years (von Korff & Eaton, 1989); characteristics of panic in Panic Disorder groups
Prevalence of Panic 405
and the other diagnoses. The report of dizziness outlined above, there is some evidence that
and fear of going crazy or losing control were panic attacks precede the development of Panic
significantly higher in the Panic Disorder Disorder. Von Korff and Eaton (1989) make an
patients, a finding which may be of specific interesting theoretical case for Panic Disorder
relevance to psychological hypotheses which as a sequenced and staged problem. The
emphasize bodily sensations and their misinter- sequence proposed is based on that suggested
pretation signs of catastrophe. Boyd (1986) has by Klein et al. (1987), and runs as follows:
reported high rates of panic in patients diag- (i) occurrence of panic attacks;
nosed as part of the ECA study; especially (ii) cognitive appraisal of symptoms as
striking in this study are the panic comorbidity harmful;
figures of 28±62% in schizophrenia. (iii) sensitization to symptoms; and
From a different perspective, panic has (iv) development of avoidance.
usually been described in association with a These stages are said to represent different
number of clinical phenomena, particularly phases in the development of a disease. Agor-
avoidance behavior and agoraphobia. It has aphobia is thus said to represent a later stage of
been suggested elsewhere (Salkovskis, 1988a) Panic Disorder. The evidence supporting this
that the definition of avoidance behavior epidemiologically-based view is scanty and, in
associated with panic attacks needs to be some instances may be contradictory. For
broadened to include more subtle aspects of example, Thyer, Nesse, Cameron, and Curtis
avoidance behavior, particularly the immediate (1985) demonstrated that, in their sample, Panic
reactions to panic such as holding on to Disorder patients have a (nonsignificantly)
supermarket trolleys, using distraction and so longer duration of disorder compared to agor-
on. aphobics. The disease-stage model would pre-
A further likely association is with health dict a significantly shorter duration. The link
anxiety or hypochondriasis, dealt with in between Panic Disorder and Agoraphobia is
greater detail below. The structure of the discussed in detail in Salkovskis (1988a); it is
interview for DSM-III is such that hypochon- concluded that the data is consistent with two
driasis is not classified as an Anxiety Disorder, possibilities; either that important idiosyncratic
but instead is part of the Somatoform Disorders individual differences in the reaction to anxiety
Group. For this reason, Barlow et al. (1985) did and panic may be involved, or that there may be
not include screening for hypochondriasis in a difference in severity, with agoraphobia with
their study of the prevalence of panic in other panic representing the more severe variant
disorders, and this has not yet been evaluated in (Pollack & Smoller, 1995).
any other study. From a somewhat different A further shortcoming of the disease-stage
perspective, Noyes, Reich, Clancy, and O'Gor- model is the implication of a passive relation-
man (1986) used a measure of Hypochondriasis ship between panic and avoidance such that
(Pilowsky's Illness Behaviour Questionnaire avoidance is caused by panic. There is a
(IBQ)) and found that scores of 60 patients considerable amount of data supporting Marks
with Panic Disorder and Agoraphobia were (1987a, 1987b) assertion that a functional
similar to norms obtained from groups of relationship exists between agoraphobia and
Hypochondriacal patients. In the same study, panic and vice versa; not least is the demonstra-
good treatment outcome in respect of panic was tion that exposure treatments not only reduce
associated with a significant improvement in avoidance but also ameliorate panic attacks
IBQ scores. One of the main reservations of this (Marks et al., 1983; see also review in
study concerns the use of the IBQ, which is a Michelson, 1988). Again, all concerned con-
poor measure of hypochondriasis. clude that the requirements for longitudinal
studies are paramount (Klein et al., 1987;
Marks, 1987a).
6.18.3.5 Natural History of Panic
The absence of high-quality longitudinal 6.18.3.6 Other Issues
studies means that little is known definitively
about the natural history of panic and Panic There are a range of other issues relevant to
Disorder. In general, it appears that, in some the phenomenology and assessment of panic
patients, an anxiety diathesis is present in attacks and Panic Disorder; these are reviewed
childhood and that chronicity is common in Barlow (1988), Rachman (1990), and Sal-
(Degonda & Angst, 1993; Pollack et al., 1990; kovskis (1988a). The main questions posed can
Pollack & Otto, 1997). Most information comes be summarized as follows:
from cross-sectional studies, and is subject to a (i) Is panic qualitatively distinct from other
range of problems such as cohort effects. As forms of anxiety?
(ii) Is there a dimensional basis for panic, point behavioral theories have not directly
with the presence of Panic Disorder reflecting contributed to the debate on the nature of
an extreme score on an underlying psychologi- panic, and for a variety of reasons tend to
cal dimension; if so, what is the nature such a become aligned with cognitive views in the form
continuum? of cognitive-behavioral approaches (Hawton,
(iii) Is there a difference between cued and Salkovskis, Kirk, & Clark, 1989; Salkovskis,
uncued (ªspontaneousº) panic attacks? 1986). For detailed accounts of older behavioral
These issues have not been fully resolved approaches to the understanding of agorapho-
(Salkovskis, 1988a); however, it now seems bic behavior, the interested reader is referred to
most likely that the answers to such questions Foa et al. (1984), Hallam, (1978, 1985), Marks
will depend less on epidemiological and phe- (1981, 1987b), Mathews, Gelder, and Johnston
nomenological studies and more on experimen- (1981), and Rachman (1990).
tal investigations based on the evaluation of
particular theories of the nature of panic. 6.18.4.1 The Original Biological Hypothesis:
Klein's View
6.18.4 THEORIES OF PANIC The importance of Klein's hypothesis goes

beyond its intrinsic value, both because it
There are two main approaches to the resulted in the adoption of pharmacotherapy
conceptualization of panic attacks. These are: as the dominant North American treatment
(i) Biomedical hypotheses, which consider approach to panic and because other biological
that Panic Disorder is an illness or disease with theories which developed later have tended to
a specific pathophysiology (caused by a lesion, a take his views and evidence as their own starting
biochemical deficiency, or some other abnorm- points. For this reason, the foundations of this
ality of structure or function). These hypotheses theory will be considered particularly carefully.
include Klein's original position, his Klein (1980, 1981; Klein & Klein, 1988, 1989a,
suffocation-alarm hypothesis, Charney's neu- 1989b) argues that several findings indicate a
ropharmacological hypotheses, Leibowitz et qualitative distinction between panic anxiety
al.'s detailed neuroanatomical hypothesis, and and anticipatory or phobic anxiety. These are:
the physiological/hyperventilation syndrome (i) the apparently spontaneous nature of some
theories of Lum and Ley. panic attacks; (ii) the observation that panic but
(ii) Psychological hypotheses, which propose not anticipatory anxiety responds to antide-
that panic is the outcome of normal processes pressant medication (Sheehan, 1982), and that
which may be quantitatively but not qualita- panic does not respond to phenothiazines or (as
tively different from everyday experience. These shown later) benzodiazepines; (iii) the finding
include van den Hout's interoceptive condition- that patients have experienced more separation
ing hypothesis and the cognitive hypotheses anxiety and school ªphobiaº (50%) than mixed
advocated by Beck, Clark, Ehlers, and Salkovs- psychiatric controls who were not diagnosed as
kis. Barlow's ªfalse alarmº hypothesis is de- suffering from Panic Disorder (27%)
scribed here as psychological because many of (Gittleman-Klein & Klein, 1984; Klein, 1964);
the processes invoked are psychological in (iv) the finding that sodium lactate frequently
nature. However, it also shares a key character- precipitates panic attacks in Panic Disorder
istic with the biomedical hypothesis in that it patients but does not do so as frequently in
starts from the supposition of dysfunction in a nonclinical control subjects or socially anxious
biological ªalarmº mechanism which deter- patients (Liebowitz et al., 1984; Liebowitz,
mines the uniqueness of panic. Fyer, et al., 1985; Pitts & McClure, 1967); (v)
As Seligman (1988) and Rachman (1990) evidence of a familial (possibly genetic) com-
comment, the debate between the two positions ponent in panic; particularly the higher con-
concerning panic has considerable implications cordance rate for panic in monozygotic as
in other areas, being the ªcenterpieceº of the compared to dizygotic twins (Crowe, Pauls,
debate between two competing models of Slymen, & Noyes, 1980; Torgerson, 1983).
psychopathology. Klein regards panic as similar to epilepsy,
Despite the major redefinition which was with uncontrolled discharges of activity in the
involved in DSM-III, earlier behavioral con- biobehavioral anxiety system producing semi-
ceptualizations of phobic anxiety and Agor- random bursts of activity which manifest as
aphobia remain of vital importance (cf. Marks, panic attacks. This is said to happen because a
1987a; Salkovskis & Hackmann, 1997) and have normally stabilizing negative feedback loop has
much to say about the implications of phobic become converted to a pathological positive
avoidance behavior (particularly agoraphobic feedback loop, possibly as a result of sensitizing
avoidance and its treatment). However, at this separation experiences during childhood. All
Theories of Panic 407
other panic-related phenomena follow on from out by Marks et al., 1983; see also Marks,
these bursts of pathological activity, including 1987a), this conclusion is not supported by a
Agoraphobia (Klein et al., 1987). large number of other well-conducted studies
Klein's position has been criticised as being (Clum & Pendrey, 1987; Klein & Klein, 1989a,
too vague, especially in terms of the failure to pp. 151±153). The more convincing reservation
specify the exact nature of the disordered (Telch, Tearnan, & Taylor, 1983) focuses on
mechanism (Rachman, 1990). There have been whether or not the effectiveness of imipramine is
a variety of critiques of the evidential basis of independent of the self-exposure instructions
Klein's theory; these are fully discussed in Clark which invariably accompany pharmacological
(1986a, 1986b, 1988), Margraf, Ehlers, and treatment. The effectiveness of such instructions
Roth (1986), Rachman (1990), and Barlow on their own and combined with pharmacolo-
(1988). In the order specified above, these can be gical treatments has been the subject of much
summarized as follows. investigation. At present, there is some evidence
(i) The degree of spontaneity of panic, even that the effects of imipramine and self-exposure
early attacks, is debatable; in the longer term, instructions might be synergistic (Margraf &
work such as that reported by Faravelli (1985), Ehlers, 1989; Telch et al., 1983). Finally, a
Finlay-Jones and Brown (1981), Pollard, Pol- number of authors have pointed out that the
lard, and Corn (1989) and reviewed in Roy- effectiveness of a particular treatment modality
Byrne and Uhde (1988) indicates that threat- (i.e., biological or psychological) is not convin-
related life events tend to precede the onset of cing evidence favoring the basis of a disorder in
panic. In more immediate terms, there is that modality (Clark, 1988; Rachman, 1990).
evidence that acute panic is often preceded by (iii) A number of carefully controlled studies
identifiable stimuli such as bodily sensations and (including prospective ones) have failed to find
frightening thoughts (Beck, Laude, & Bonhert, differences between panic patients and others in
1974; Hibbert, 1984). These interview studies terms of separation anxiety and school phobia
have received support both from studies 24 hour (Berg, Butler, & Pritchard, 1974; Coyrell,
ambulatory psychophysiological monitoring Noyes, & Clancy, 1983; see also reviews by
(reviewed in Freedman, 1989) and from work Margraf, Ehlers, & Roth 1986a, 1986b, and
using telemetry and computer based in situ Tearnan, Telch, & Keefe, 1984). Earlier asser-
questionnaires (Taylor, Fried, & Kenardy, tions in this respect were largely based on
1990). retrospective reporting.
(ii) The initial supposition (Klein & Fink, (iv) 40% or more of panic patients do not
1962) that phenothiazines were specifically panic when sodium lactate is administered. This
anxiolytic in generalized anxiety has not been observation is not consistent with the hypoth-
supported by subsequent research. In later esis that response to lactate is a specific
work, the emphasis of the ªpharmacological ªbiological markerº for the mechanisms in-
dissectionº shifted to the demonstrably anxio- volved in naturally occurring panic attacks.
lytic benzodiazepine class of drugs. Early Data from the Oxford group indicates that, far
studies suggested that the benzodiazepine class from being impervious to psychological influ-
of drugs were not effective in the treatment of ences as previously argued (Klein, 1981), the
panic attacks (McNair & Kahn, 1981), whilst a anxiety-provoking effects of lactate in panic
range of outcome studies continued to provide patients can be blocked by instruction (Clark
evidence for the specific efficacy of tricyclic et al., in preparation). A further problem for
antidepressants (Garakani, Zitrin, & Klein, Klein's original position is the fact that sodium
1984; McNair & Kahn, 1981; Zitrin, Klein, lactate infusions are only one of a range of
Woerner, & Ross, 1983). However, there is now ªbiological challengesº which have the effect of
a considerable amount of evidence available for provoking panic attacks in Panic Disorder
short-term (i.e., over a period of six weeks) patients; the range of such panic-provoking
beneficial effects of benzodiazepine administra- challenges is remarkably wide, including adre-
tion in panic, particularly the triazolobenzo- naline, caffeine, increased carbon dioxide,
diazepine alprazolam (Ballenger et al., 1988), hyperventilation, isoproterenol, m-CPP, and
but also to higher doses of more conventional yohimbine (see reviews by van den Hout &
benzodiazepines such as diazepam (Noyes et al., Griez, 1986; Margraf, Ehlers, & Roth, 1986a,
1984). However, the efficacy of imipramine as 1986b); Uhde & Tancer, 1989). The importance
an effective treatment for Panic Disorder is now of the finding that all of these diverse provoca-
well established (Ballenger, 1986; Sheehan, tions produce a panic response in panic patients
Ballenger, & Jacobsen, 1980). Despite Marks' is the fact that these challenges have not been
assertion that the antipanic effects of imipra- identified as having any commonality in terms
mine are mediated by its specific antidepressant of either their biochemical or physiological
action (based on the results of the study carried effect. Thus, it is very unlikely that they are all
working on the same mechanism, and no view In later theoretical writings, Klein and Klein
has yet been proposed concerning possible (1989a, 1989b) suggest that the specific mechan-
multiple inter-related influences involved in ism of panic may involve an evolutionarily
the biochemical triggering of panic. It is evolved central alarm mechanism which func-
therefore not clear whether some biochemical tions in relation to separation anxiety or
inductions are valid models of naturally impending asphyxia, and that catastrophic
occurring panic and others are not, whether cognitions are incidental to this biological
none are, and so on. As will be described below, mechanism. He argues that ªMany spontaneous
a psychological account best encompasses the panics occur when the brain's suffocation
full range of inductions used, and does so in a monitor erroneously signals a lack of useful
particularly parsimonious way. air, thereby maladaptively triggering an evolved
(v) The evidence for a familial component is suffocation alarm systemº (Klein, 1993; see also
relatively stronger than other evidence for the Klein, 1996). Again the suggestion is that panic
biological hypothesis (Kendler, Heath, Martin, is relatively impervious to psychological influ-
& Eaves, 1987). However, there are some distinct ences. The evidence against the ªirrelevanceº of
oddities in the concordance data which are psychological influences is now overwhelming.
difficult to make sense of from the standpoint of There have been a number of more direct tests of
a genetic diathesis for the occurrence of panic the suffocation/alarm system which suggest that
attacks. For example, groups of relatives who it is not correct (e.g., Taylor, Woody, Koch,
should show similar genetic risk have been McLean, et al., 1996).
shown to have widely differing rates of panic and
other anxiety disorders. Dizygotic twins were 6.18.4.2 The Neuroanatomical Hypothesis
shown by Torgersen (1983) to have lower panic
concordance rates than nontwin siblings, and A group of researchers from Klein's center
concordance between siblings is less than proposed a ªneuroanatomical hypothesis,º
between parents and children (Moran & An- which they describe as being inspired by his
drews, 1985). The extent to which familial risk work (Gorman, Liebowitz, Fyer, & Stein, 1989).
for Panic Disorder differs from that for General- This complex hypothesis takes Klein's basic
ized Anxiety Disorder is a subject of debate assertions (p. 26) as its starting point, but
(Margraf et al., 1986a, 1986b). Margraf and attempts both to make the position more
others have suggested that concordance rates are explicit and to identify the neuroanatomical
only high for panic when liberal diagnostic basis of the components of the hypothesis. The
criteria are used (i.e., when the presence of panic paper also attempts to incorporate cognitive-
is recorded because of what are described as behavioral findings and circumvent the psycho-
limited symptom attacks [increases in anxiety logical/biological debate described above
involving less than the four symptoms required (p. 25). They argue that it is not useful to
by DSM-III]) as opposed to the full diagnostic attempt to specify whether panic is ªa beha-
criteria for Panic Disorder. That is, it is not vioural cognitive diseaseº (sic) or ªa biological
possible to rule out the suggestion that relatively disease,º and that it should be regarded as
mild symptoms of general anxiety are being having elements of both. By describing the basis
inappropriately identified as panic attacks. This of their hypothesis in this way, they seem to
view is consistent with the findings that those misconstrue the basis of the debate, which is not
studies finding the highest concordance for biological vs. psychological, but disease vs.
panic also find the lowest concordance for nondisease (Rachman, 1990). The neuroanato-
Generalized Anxiety Disorder. Barlow (1988, mical hypothesis proposes that:
pp. 172±174) summarizes this data, and pro-
poses that the evidence on the heritability of there are three distinct components of the illness
anxiety is most consistent with the hypothesis of Panic DisorderÐthe acute panic attack, anticipa-
tory anxiety and phobic avoidance. These three
the trait of anxiety (often described as emotion-
clinical phenomena arise from excitation of three
ality, nervousness, or neuroticism). He argues distinct neuroanatomical locations, respectively:
that studies reporting a difference between the brainstem, limbic lobe, and prefrontal cortex.
heritability for Panic Disorder and other anxiety Reciprocal innervation among nuclei in these three
disorders have not controlled for the fact that all centres explains the genesis of the disease and its
Panic Disorder subjects are generally anxious clinical fluctuations over time. (Gorman et al.,
with different levels of severity which are 1989, p. 149)
inherent in the structure of the DSM-III
diagnostic rules. When severity of disorder is Like Klein's view, the model proposed is a
taken into account, Barlow points out that the disease-stage one, with acute panic being the
different anxiety disorders appear to be equally necessary first stage, followed by the develop-
heritable. ment of anticipatory anxiety and agoraphobic
avoidance. The problem of the development of The evidence for a link between the limbic
agoraphobia without preceding panic attacks is system (ªlimbic lobeº) and anticipatory anxiety
acknowledged (Gorman et al., p. 149) but not is somewhat more consistent, being mainly
dealt with except by suggesting that ªphobic derived from the work of animal researchers
avoidance and anticipatory anxiety could con- such as Gray (1982). The specific involvement of
ceivably be maintained without the induction of this system in Panic Disorder in man is more
panic if only these reciprocal pathways between difficult to justify. Little evidence supporting
prefrontal cortex and limbic areas were in- such a link is presented, other than general
volvedº (Gorman et al., p. 156). Gorman et al. allusions to the vulnerability of the limbic
specify that the complexity of the hypothesis system to the generalization of spasmodic CNS
means that a great many experiments will be electrical activity (ªkindling effectsº) coupled
required to validate or disprove the model; they with speculation that general anxiety associated
also argue in their conclusion that, because the with panic might result from such kindling
disorder is complex and involves so many facets, effects. The importance of the limbic system to
it requires a complex theory to account for it the neuroanatomical model is related in large
(p. 158). Perhaps the principal problem with this part to the proposition that it is through this
position is the fact that they do not specify any system that nonpharmacological interventions
differential predictions vis-aÁ-vis alternative hy- (particularly exposure) have their effects. It is
potheses, relying instead on a proposed synthesis difficult to see how the propositions made
which incorporates alternative accounts (ªcom- concerning the role of limbic system can be
bined rather than opposed,º p. 158). However, evaluated directly, and whether this component
they do insist on the basic assumption of ªthe of the hypothesis in any way advances the
neural circuits of the brain as the basis for understanding of mechanisms involved in panic
pathology.º attacks and their treatment.
The argument for a brainstem basis of acute The prefrontal cortex is linked to panic and
panic is based on the physical character of panic anticipatory anxiety by its presumed cognitive
symptoms and the biochemical panic provoca- function; it is here that interpretations are
tion studies discussed above in the context of linked to brainstem discharge, according to the
Klein's theory. The suggestion is that the various model. The extensive innervation (afferent and
panic-provoking agents produce paroxysmal efferent) of this area is said to make it
brainstem activity as a result of activity in one or particularly suitable for such a function. Again,
more specific brainstem loci. However, the no specific evidence in support of a link with
central basis of at least one panic-provoking panic is offered other than previous general
agent, isoproterenol (which provokes panic at studies into the possible function of the
the same rate as lactate infusions; Rainey et al., prefrontal cortex. If this aspect of the hypothesis
1984), is particularly hard to explain in these is correct, then it may be possible to evaluate
terms as it does not cross the blood±brain barrier this directly by experiments involving patients
(Conway, Tejani-Butt, & Brunswick, 1987) and who have previously been subject to psycho-
therefore cannot have its panic-provoking surgery in this region.
effects as a result of direct action on the brain- Perhaps the most valuable aspect of Gorman
stem. Gorman et al. discuss yohimbine as an et al.'s paper is that it offers specific predictions
exemplar of a panic-provoking agent because its which are said to allow experimental testing of
action is relatively well understood; it has the the hypothesis. These predictions generally
effect of increasing CNS noradrenergic activity, specify the likely locus of brain activity which
particularly in the locus coeruleus and pontine should accompany various forms of stimulation
nucleus. The effect of yohimbine in activating and treatment. The prediction which is parti-
the brainstem noradrenergic activity which is cularly relevant to psychological hypotheses
hypothesized to be implicated in panic is des- concerns treatment, specifically that cognitive-
cribed in some detail (Gorman et al., p. 156). The behavioral treatments will leave a core of
role of clonidine, which has the opposite effect to occasional panic attacks (whilst drug treatments
yohimbine on noradrenergic activity, is more will not) because cognitive-behavior therapies
briefly alluded to; two studies of the effects of ªexert ameliorative effects at a different ªsite' of
clonidine in panic patients are cited as additional disease progression than do antipanic drugsº
evidence of the proposed noradrenergic hyper- (Gorman et al., p. 157). This proposition
sensitivity in panic patients (Charney & Henin- already seems to have been invalidated (Clark
ger, 1986; Nutt, 1986). However, as is described et al., 1994; Clark, Salkovskis, & Chalkley,
below (p. 39), although the results of these clon- 1985; see also below).
idine studies appear to show an abnormality, it is Altogether, the neuroanatomical hypothesis
not consistent with a simple hypersensitivity as is disappointing in that it does not utilize new
proposed by the neuroanatomical model. data, and seems to explain less than Klein's
original hypothesis. The attempted integration is and caffeine, are known to stimulate the LC,
unhelpful because it retains the basic proposition while drugs which have an antipanic effect are
of a disease process, and because psychological known to depress LC activity (e.g., tricyclic
factors are only included in the account as antidepressants; but also diazepam).
secondary phenomena to the unmodified ªfactº There are a number of problems with the LC
of biologically determined panic. That is, all hypothesis. There are doubts about the general-
psychological factors are considered to operate izability of much of the animal research upon
ªdownstreamº of fundamental biological me- which it is based (Mason, 1981), and a variety of
chanisms modifying the secondary response to findings from well-conducted studies contradict
panic itself, with the most minimal of interac- the earlier positive results. For example, bio-
tions even at this secondary level. This position chemically specific noradrenergic LC lesions in
does not take account of the wide range of rats do not impair the response to threatening
psychological findings described below. The stimuli (File, Deakin, Longden, & Crowe, 1979)
problems associated with the empirical founda- and do not impair the acquisition of one-way,
tions of Klein's position (described above) two-way, and Sidman avoidance responses, nor
remain unresolved by this newer theorizing. modify conditioned suppression. In humans, the
effect of LC and central noradrenergic distur-
6.18.4.3 Neurochemical Hypotheses: bances are impaired perceptual organization
Noradrenaline and the Locus Coeruleus and memory, disorientation, hallucinations and
delusions, with anxiety not being a prominent
Some of the most scientifically interesting feature (van Dongen, 1981). Drugs such as
work on biological approaches to panic has buspirone and carbamazepine which increase
emanated from Charney's group (Charney & LC activity and mianserin which blocks the
Heninger, 1986), who have concentrated on a activity of alpha2-autoreceptors do not induce
neurochemical hypothesis in which it is pro- panic, and have been shown to be therapeutic in
posed that panic attacks are a result of some instances. The evidence for Charney's LC
dysregulation in the noradrenergic system. This hypersensitivity hypothesis is not particularly
work formed an elaboration of earlier basic convincing. However, this line of research has
research in primates implicating the locus generated a series of findings in panic patients
coeruleus (LC) in fear situations and behaviors. which are not readily explained by any other
Redmond and colleagues found that direct position, and which suggest some biological
stimulation of the LC in stump-tailed monkeys differences between panic patients and noncli-
results in a behavioral response said to mimick a nical subjects. Charney and Heninger (1986),
human panic attack; the monkeys displayed Nutt (1986), and Uhde, Siever, and Post (1984)
behaviors characteristic of fear in the wild (e.g., evaluated the response to the alpha2-receptor
scratching and grimacing) (Redmond, 1985; agonist clonidine in panic patients and non-
Redmond & Huang, 1979). Ablation of the LC clinical controls. They found that panic patients
in monkeys was associated with less fear show a modified hormonal response (signifi-
responses when in the presence of anxiety- cantly greater decreases in the noradrenergic
provoking stimuli, as was the administration of metabolite MHPG (3-methoxy-4-hydroxy-
many antianxiety drugs (Redmond, 1979; 1985; phenylglycol) and smaller increase in growth
Redmond & Huang, 1979). Charney and hormone) and greater decreases in blood
Heninger (1986) argue that the importance of pressure (but not heart rate). While these
the noradrenergic LC system lies in its respon- differences cannot satisfactorily be explained
sivity to sensory input and the ramifications of in any detail by the LC hypothesis as originally
this system throughout the cortex. They propose stated, they might indicate what Charney
that ªabnormally high responsivity of brain describes as a ªdysregulation,º involving both
noradrenergic systems is etiologically related to over- and under-responsiveness of different
the development of panic disorders.º In parti- subsystems, perhaps even the same subsystems
cular they focus on the possible importance of at different times. This line of research may be of
alpha2-adrenergic presynaptic receptors (auto- interest if it can be shown that the key results can
receptors), which regulate the release of nora- be replicated when panic patients are compared
drenaline within their own neurones through a to anxious controls.
negative feedback mechanism. Charney pro-
posed that impairment of this inhibitory me- 6.18.4.4 Physiological Accounts of Panic: Panic
chanism leads to inappropriate paroxysmal as a ªHyperventilation Syndromeº
discharges in the arousal system in response to
low levels of stimulus input. Evidence for this The notion that panic attacks may occur as a
position was derived from the fact that some result of episodic hyperventilation is an old one
panic-inducing substances, such as yohimbine which has recently been enthusiastically revived
(Hibbert, 1984; Ley, 1985a, 1985b). It has in paCO2 levels in the production of symptoms
periodically been suggested since the 1930s that has also led to a specific proposal concerning the
the physiological effects of breathing in excess of role of hyperventilation in the vulnerability to
metabolic requirements could account for acute episodes of panic symptoms. It has been
sudden severe attacks of anxiety accompanied proposed that panic patients are vulnerable to
by a wide range of bodily sensations (e.g., such acute episodes of panic arising from
Gibson, 1978; Kerr, Dalton, & Gliebe, 1937; see hyperventilation because of a chronic, asymp-
also review by Magarian, 1982). Briefly, the tomatic hyperventilation (Lum, 1976). Thus, it
hyperventilation hypothesis is that, under con- is argued that frequent hyperventilation leads to
ditions of stress, patients breathe in an excess of the blood buffering system ªresetting,º so that a
metabolic requirements, that is, they breathe out constantly lowered paCO2 is present at all times,
more CO2 than they produce. When this but only becomes symptomatic when a further
happens, it results in a ªblowing offº of CO2. acute drop occurs, which will occur relatively
That is, because of the more rapid movement of frequently because the reset buffering system is
air in and out of the patient's lungs, more CO2 more reactive to small paCO2 changes.
than usual diffuses out of the pulmonary blood Hyperventilation therefore provides an ap-
vessels and into expired air, resulting in a drop in parently simple and clinically appealing expla-
the partial pressure of arterial CO2 (paCO2). nation of an otherwise complex and perplexing
Because CO2 is dissolved in blood as carbonic phenomenon, and this type of hypothesis has
acid (as part of the pH buffering system), the enjoyed intermittent popularity and ªrediscov-
effect of decreased paCO2 is an increased eryº every few years. The recently renewed
alkalinity of blood, usually described as a attention to the proposed link between panic
ªrespiratory alkalosis.º In physically healthy anxiety and respiration probably arises from the
subjects, respiratory alkalosis produces a range emphasis currently placed on the diagnostic
of physical sensations, potentially including importance of panic attacks and the search for
most of those regarded as symptoms of panic. biological explanations and treatment already
Thus, it has been argued that panic attacks are described above. This is because explanations
caused by or are even synonymous with episodes based on the idea of ªhyperventilation syn-
of acute hyperventilation. dromeº invariably have an implicit basis in
Normally, respiratory alkalosis is self-cor- biomedical ideas of underlying dysfunction or
recting, in that respiration self-regulates; low- pathology of respiratory control.
ered paCO2 results in the activation of a range of
negative feedback mechanisms, such as in-
6.18.4.4.1 Evidence for an association between
creased tone in the chest wall (intercostal)
panic and hyperventilation
muscles. Note that increased breathing rate or
depth are not necessarily indicative of hyper- The evidence for an association between
ventilation; only blood CO2 levels (as measured panic and hyperventilation is considerable.
directly from arterial blood [paCO2] or the However, this falls far short of evidence for
mixed venous [pmvCO2] systems) give true causation. First, it has frequently been observed
indications of whether hyperventilation is that voluntary hyperventilation reproduces
occurring or not, and the degree to which it is symptoms similar to those experienced during
present. It also appears that it is not the absolute panic attacks, including increased anxiety (e.g.,
level of paCO2 which is important, but is instead Lum, 1976). Second, substantial drops in paCO2
the extent to which this variable shows a rapid levels have been observed as a result of
decrease. This has been shown in an elegant way contrived and naturally occurring stressors in
by Hout van den and Griez (1985), who carried panic patients (Hibbert, 1986; Salkovskis,
out an experiment on breath-holding after CO2 Clark, & Jones, 1986; Salkovskis, Warwick,
inhalations. They demonstrated that the symp- Clark, & Wessels, 1986) and in normal subjects.
toms induced by inhalations of 35% CO2 in Third, a number of studies have reported that
65% O2 did not arise from the increased carbon panic patients have significantly lower resting
dioxide associated with the inhalation, but by levels of paCO2 than normal controls (Gorman
the subsequent rapid fall which occurs when an et al., 1987; Gorman et al., 1986; Rapee, 1986;
inhalation is released and followed by a reflex Salkovskis, Jones, & Clark, 1986), possibly
hyperventilation and unusually large decrease indicating the occurrence of renal compensation
in paCO2. (See Hardonk & Beumer, 1979, and for repeated acute hyperventilation (ªresettingº
Lum, 1976, for more detailed accounts of of the buffer system; Gledhill et al., 1975). That
physiological factors involved in hyperventila- is, if hyperventilation (and therefore the
tion; Hibbert (1984) provides a concise account respiratory alkalosis) is prolonged, the meta-
of the simplest form of the hyperventilation bolic response involves excretion of bicarbo-
hypothesis of panic attacks.) The role of change nate, which restores the acid/base balance at a
lower level of paCO2. Fourth, respiratory concentration of CO2 passing across the skin
symptoms and fears are particularly prominent (transcutaneous CO2) and record the informa-
among panic patients (Pollard, 1986) and tion on a miniaturized belt-mounted recorder
symptoms associated with hyperventilation while the patient goes about their normal
are significantly more likely to occur in panic business. This measure of transcutaneous CO2
patients than in patients suffering from general has been shown to correlate highly with arterial
anxiety disorder (Rapee, 1985). Finally, there CO2 (Pilsbury & Hibbert, 1987). Studies using
have been a number of reports of the success of this measure have shown that some patients do
treatments which contain an element of re- not hyperventilate during panic attacks (Hib-
spiratory control (Clark et al., 1985; Lum, 1976; bert, 1986; Hibbert & Pilsbury, 1989). The
Salkovskis, Jones, & Clark, 1986), and that effectiveness of treatment involving elements of
successful psychological and physical treatment respiratory control has been taken as evidence
results in a significant decrease in resting paCO2 for the hyperventilation hypothesis. Early
(Gorman et al., 1987; Salkovskis & Clark, cognitive treatments emphasized respiratory
1986). control as part of a broader program of
treatment directed at reattribution. Hibbert
and Chan (1989) attempted to replicate the
6.18.4.4.2 Hyperventilation as a CAUSE or
Clark et al. (1985) and Salkovskis, Jones, and
EFFECT of panic
Clark (1986) findings for respiratory-based
Ley (1985a, 1985b) strongly argues that treatment but without the inclusion of a
hyperventilation causes panic. In a formulation cognitive element; the results of this relatively
very similar to previous ªhyperventilation large study suggest that the effectiveness of
syndromeº hypotheses (Garssen, van Veenen- previous treatments may have been due to the
daal, & Bloemink, 1983; Hardonk & Beumer, cognitive element, and is certainly not likely to
1979; Lum, 1976), he proposed that ªthe panic be accounted for by the physiological basis of
attack is unique, that it consists of a synergistic respiratory control alone.
interaction between hyperventilation and fearº Nevertheless, while it is difficult to support
(Ley, 1985b, p. 272). The basis of the relation- the view that hyperventilation causes panic, it is
ship between fear and hyperventilation is said to also difficult to maintain the view that acute
be found in the way in which fear activates the hyperventilation, when it occurs, is irrelevant to
sympathetic nervous system and thence drives the experience of panic. The differences re-
the intercostal muscles of the thorax, thus ported between panic patients and control
increasing respiration. Ley regards the occur- subjects in resting CO2 seem certain to result
rence of hyperventilation as the crucial (neces- in reduced blood buffering capacity and should
sary) factor for panic to occur, and states that have the effect of making panic patients more
ªthe crucial assumption is that sensitive in- prone to experiencing substantial respiratory
dividuals who have recently experienced stress- changes in response to relatively minor chal-
ful events are constantly overbreathing and, lenges. In a consecutive series of single-case
therefore, on the brink of respiratory alkalosisº experiments with panic patients, very substan-
(Ley, 1985b, p. 281). tial drops in paCO2 occurred as a response to
The foundations of this approach do not mild specific psychological stressors (Salkovs-
substantially differ from other attempts to kis, Clark, & Jones, 1986, discussed together
account for panic attacks as part of a centrally with other related data in Salkovskis & Clark,
determined defect of respiratory control. As 1986). It was concluded in this paper that the
with previous statements of the hyperventila- rapidity and magnitude of the observed changes
tion hypothesis, the way the role of fear is dealt in CO2 were sufficiently large to infer that a
with presents some problems, although it is at symptomatic respiratory alkalosis must at least
least considered in some detail. Fear is said to have contributed to the symptoms experienced.
arise either as a direct physiological effect on the That similar profound changes can be observed
autonomic nervous system, or the intensity of in a proportion of naturally occurring panic
the symptoms in some direct (and unspecified) attacks has been demonstrated by a single case
way produces fear and alarm. An interaction in which it was possible to directly measure
between fear and overall levels of stress and arterial paCO2 and pH (Salkovskis et al., 1986)
sensitivity to fear is proposed, as well as and by a study using ambulatory measures of
individual differences in the respiratory system transcutaneous CO2 (Hibbert & Pilsbury, 1989).
and its reactivity. There is evidence from a study on the clinical
Most problematic for the view that hyper- presentation of anxiety disorders that the main
ventilation is a necessary cause of panic attacks symptoms which trigger thoughts of physical
are the results of work on ambulatory monitor- and mental harm in panic patients (but not in
ing of CO2. This technique measures the generally anxious patients) are the symptoms
Psychological Theories of Panic 413
commonly produced by hyperventilation (Ra- differential predictions have, as yet, been

pee, 1985). identified for any of these other psychophysio-
It thus appears that it is not possible to logical models which have been proposed to
account fully for panic by invoking concepts account for cognitive±physiological interac-
such as ªhyperventilation syndrome,º but tions (Ehlers & Margraf, 1989); Clark's
neither does it seem possible to totally discount (1986a, 1986b) hypothesis therefore remains
a role for hyperventilation in the production of the most parsimonious and influential of these.
symptoms experienced during panic attacks.
The way in which the hyperventilation hypoth-
esis enjoys periodic popularity has been based 6.18.5.1 Barlow's Model: False Alarms and
on the fact that there is indeed compelling Learned Alarms
evidence of an association with anxiety, and on
enthusiastic clinical reports of the efficacy of Barlow's model (Barlow, 1988, 1991) is
treatments involving breathing exercises (Lum, particularly interesting because it is presented
1975, 1976). Any hypothesis must therefore in the context of a major monograph in which he
reconcile the strong evidence for an association attempts to develop an overarching theory
between hyperventilation and panic with the relevant to all anxiety disorders and to synthesise
equally strong evidence that hyperventilation is conditioning, neurobiological and psychosocial
neither necessary nor sufficient for the occur- factors. He acknowledges that the result lacks
rence of panic. After reviewing psychological specificity at times, although he also expresses
hypotheses of panic, I will return to consider a the hope that it represents a testable set of
cognitive explanation of the relationship be- propositions. Interestingly, the model bears
tween panic and hyperventilation. some resemblance to the neuroanatomical
hypothesis (p. 32), in that it is a disease-stage
model with an emphasis on concepts of
6.18.5 PSYCHOLOGICAL THEORIES OF malfunctioning subsystems. Unlike other psy-
PANIC chological models of panic, Barlow's specifically
proposes a qualitative distinction between panic
Although psychological hypotheses of panic and other forms of anxiety. The basis for the
are a relatively new development, behavioral model concerns a ªcomplex biopsychosocial
theories of agoraphobia have been generating process,º involving the interaction between ªan
research and treatment studies directly relevant ancient alarm system, crucial for survival, with
to panic since the early 1960s (see Hallam, 1985; inappropriate and maladaptive learning and
Marks, 1987b; Mathews et al., 1981). Such work subsequent cognitive and affective complica-
continues to generate valuable results, and has tionsº (Barlow, 1988, p. 209). Thus, a biological
become substantially integrated with the more (evolutionarily relevant) alarm system is postu-
recent research and theory emphasizing panic lated; this primitive system is designed to react to
attacks. Some of the most substantial and actual danger with a set of energizing responses,
important work has approached panic from the termed a ªtrue alarmº; such responses prepare
perspective of panic attacks associated with the organism to react in appropriate ways to
phobic behavior (Barlow, 1988; Rachman, threat, and are therefore associated with ªaction
1990). tendencies,º which are either escape/flight,
There are two main psychological hypotheses freezing/immobility, or aggression/attack.
of panic, both of which draw on a variety of However, under conditions of nonfocal threat
influences. These are interoceptive conditioning and consequent generalized hyperarousal (e.g.,
models (Barlow, 1988; Hout van den, 1988) during a period following a major threat-related
which are most closely modeled on theories of life event), biologically (genetically) vulnerable
classical conditioning particularly Russian individuals become prone to spontaneous dis-
work described by Razran (1961) and cognitive charges of the alarm system. Specifically, ªfalse
theories (Beck, 1988; Clark, 1986a, 1986b, 1988; alarmsº (panic attacks experienced at the outset
Salkovskis, 1988a) which are based on Beck's of development of Panic Disorder) are said to
(1976; Beck, Emery, & Greenberg, 1985) ªspike offº from a stress response in such
cognitive approach to emotional disorders. vulnerable individuals. That is, generalized
The discussion of Clark's cognitive model anxiety increases under stress and forms a kind
subsumes similar models, particularly the of platform which puts the alarm system on a
psychophysiological models described by Mar- hair-trigger and makes the sparking off of an
graf and Ehlers; as pointed out in Ehlers, alarm-type response particularly likely. This
Margraf, and Roth (1988), all such theories initial occurrence of spontaneous panic as ªfalse
(with the exception of Barlow's) share common alarms,º which are said to be characteristic of
assumptions and differ only in emphasis. No the panic attacks experienced by nonclinical
panickers may, in turn, become conditioned to mental sensations as signs of imminent personal
interoceptive stimuli if a false alarm was disaster. The anxiety engendered by the mis-
associated with such stimuli. The formation of interpretation of sensations produces an in-
such conditioned associations are particularly crease in sensations, which can in turn feed back
likely if the association occurs in a situation to the misinterpretation, rapidly culminating in
where the ability to carry through ªaction a full-blown panic attack. Thus, according to
tendenciesº is blocked. This conditioning pro- the cognitive hypothesis, panic occurs only if
cess then results in the occurrence of ªlearned sensations are misinterpreted; patients who
alarms.º For Panic Disorder to result, there is a experience repeated panic attacks are particu-
further crucial step, however. Anxious expecta- larly vulnerable to making such misinterpreta-
tion over the occurrence of negative events or tions by virtue of a pre-existing set of beliefs. A
subsequent ªalarmsº must develop, and is said variety of things may trigger off the panic
to be ªa crucial psychological vulnerability,º vicious circle in the first instance; it may be
possibly arising as a result of a ªpre-existing triggered by anxiety from general stress, by the
disposition to focus anxiety specifically on anxiety of entering a situation where panic
somatic events.º This tendency would make previously occurred, by a sensation from an
such individuals ªexquisitely sensitive to false unrelated source such as a hangover or too
alarms.º Avoidance and cognitive symptoms much coffee, by a frightening thought, and so
seem to follow on in a relatively passive way, on. It is important to note that the whole process
although this is not made more explicit than of panic generation can occur within a few
already described except as a diagram in which seconds, as the person responds physiologically
these are depicted as a noninteracting end-point and psychologically to what seems, at that time,
of the sequence. The lack of emphasis on to be a profound threat to his or her safety.
cognitive factors in the theory contrasts mark- For example, a patient may interpret palpita-
edly with Barlow and Cerny's (1988) and Rapee tions and a racing heart as a sign that he is having
and Barlow's (1989) description of treatment, a heart attack. This misinterpretation in turn
which includes a major component of cognitive results in intense anxiety and thus increases the
intervention. sensations associated with autonomic/physio-
Barlow does not himself suggest any specific logical arousal, including palpitations, tachy-
predictions from this model, nor does he cardia, dizziness, and precordial pain. This
differentiate it in this way from other hypoth- increase in intensity and range of symptoms
eses. However, he does state that ªthere should appeared to confirm the original misinterpreta-
be enough coherence within the theory to enable tion, further increasing anxiety and symptoms
investigators to design research protocols that and so on, rapidly culminating in an acute panic
result in confirmation or disconfirmationº attack.
(Barlow, 1988, p. 209). Perhaps the most striking A wide range of symptoms can give rise to
aspect of his theory for the present thesis is the misinterpretations, but the cognitive hypothesis
way in which cognitive factors are regarded as a proposes that those involved in panic attacks
passive ªdownstreamº consequence of a re- are particularly likely to be sensations which can
sponse to the experience of physiological result from autonomic or central nervous
sensations previously associated with excessive system responses to anxiety itself, given the
arousal. Cognition is thus seen as a complication immediate nature of the feedback loop. A
of a biologically initiated sequence. further factor in the readiness to misinterpret
bodily sensations should be the extent to which
the person has available any innocuous alter-
6.18.5.2 The Cognitive Hypothesis of Panic native explanations of the intense and wide-
ranging sensations associated with panic at-
A cognitive hypothesis of panic (Beck, 1988; tacks. For example, if someone were to notice
Clark, 1986a, 1986b, 1988, 1996, 1997; their heart racing, being short of breath, feeling
Salkovskis, 1988a; Salkovskis & Clark, 1986) dizzy, and found they were sweating a great deal
has been developed, based on initial work by immediately after running to catch a train,
Clark (1979) and Beck, Emery, and Greenberg misinterpretation is unlikely. The same sensa-
(1985). This fundamentally simple hypothesis tions experienced without any obvious cause
states that patients with recurring panic attacks would, at best, be bewildering and at worst be
have an enduring tendency to misinterpret taken as a sign of serious illness.
certain bodily sensations as a sign of imminent The catastrophic beliefs specified by the
disaster. The way in which this accounts for cognitive hypothesis account for the intensity
acute panic attacks is summarized in Figure 1. of anxiety and the associated physical symp-
According to the hypothesis, acute panic toms, insofar as the anxiety reaction experienced
results from the misinterpretation of bodily or would not be considered abnormal if occurring
Trigger stimulus
(internal or external
Perceived
threat
Interpretation
of sensations Apprehension
as catastrophic
Body
sensations
Figure 1 The suggested sequence of events in a panic attack.

(Reprinted with permission from Clark, 1986, p. 463).
in the context of a truly life-threatening situa- such as the person's previous experience (direct
tion. Typically, patients express very strong or vicarious) of symptoms and their meaning.
beliefs in the possibility of feared disaster during For each patient, there tends to be an internally
the attacks themselves, although in the clin- consistent and logical link between the sensa-
ician's office (when the symptoms are not tions experienced during panic and the parti-
present and a trusted individual is) patients will cular interpretations made. Some of the most
report that they do not, at that time, feel commonly occurring sensations and related
convinced that the disasters would happen. The interpretations are shown in Table 2.
apparent unexpectedness or ªspontaneousnessº The link between particular sensations and
of some panic attacks can also be accounted for; interpretations are frequently based on conven-
although the panic may start with a mild (and tional wisdom and ªcommon senseº so that the
often normal) physical sensation, if such a links are immediately obvious (e.g., shortness of
sensation triggers off the thoughts of disaster breath interpreted as a sign that the patient is
and hence a panic, the originating sensation may about to stop breathing), although the links
then be lost in the surge of much more intense, may not always be so clear to the observer
anxiety-generated symptoms which follow. unaware of the patient's specific pattern of
Often, there is no specific explanation for the beliefs.
triggering symptom; it was simply one of the Although it has not as yet been established
many ordinary physical fluctuations which most why some people begin to misinterpret bodily
people experience every day. sensations in the first place, there are two main
possibilities (which may operate in separate
ways or, more likely, in combination). Some
6.18.5.3 The Importance of the Idiosyncratic individuals may be in a transiently vulnerable
Nature of Catastrophic state because of biochemical factors (e.g., drugs,
Misinterpretations hormonal disturbances, etc.; see Roy-Byrne &
Uhde, 1988) or recent stressful life events
The misinterpretations made by individual (Finlay-Jones & Brown, 1981, Pollard, Pollard,
patients are based on aspects of their experience, & Corn, 1989), particularly when those events
Table 2 Examples of the association between symptoms and catastrophic misinterpretations occurring during
panic attacks.
Sensation Typical misinterpretations
Heart racing, pounding, palpitations I'm having a heart attack, my heart will stop, I'm dying
Breathlessness I'm going to stop breathing, suffocate
Feeling unreal and distant I'm going to go crazy, lose my mind
Loss of sensation and tingling in arms and legs I'm having a stroke
Feeling dizzy, faint, weak legs I'm going to faint, fall over, pass out
Feeling distant, tense, sweaty, and confused I'm about to lose control of my behavior
Feeling dizzy, heart pounding, chest tight, I'm dying
palpitations, flushed, tingling
concern serious illness in the patient him- or her- digm, it was found that anxious subjects were
self or in friends or relatives. Critical incidents of consistently more likely to overpredict than
an apparently less serious type may serve the underpredict the fear associated with phobic
same triggering function (e.g., hearing of a situations, and overpredictions were particu-
similarly aged colleague at work who had a larly likely to follow underpredictions. Reduc-
heart attack). Under such circumstances, pations in fear were most likely after
tients may more readily misinterpret bodily overpredictions, but there was evidence of an
sensations as harmful when they are unable to inherent bias towards overprediction of aversive
generate any convincing innocuous explana- events, including both anxiety provocation and
tion. Second, particular attitudes and assump- pain (Rachman & Bichard, 1988). Rachman
tions may predispose patients to the (1990, chap. 17) proposes that if agoraphobics
misinterpretation of particular circumstances, show the same type of tendency as people with
especially those concerning the effects of other types of fear to overpredict, then
anxiety. An individual who held the belief that avoidance behavior may be a product of
anxiety can kill may become alarmed as they go overprediction. Rachman goes on to suggest
through a period of intense anxiety (due, for that, in agoraphobia as in claustrophobia, the
example, to excessive job stress or illness) at a occurrence and intensity of panic attacks will
level which they had not previously experienced. form the basis of predictions of fear. He also
A substantial subgroup of such attitudes have suggests that the anticipation of fear may itself
been subsumed under the heading of ªAnxiety provoke situational panic attacks, and that the
sensitivityº (Reiss, Peterson, Gursky, & occurrence of such panic in turn affects
McNally, 1986), which has previously been subsequent avoidance. Although this view is
shown to be high in panic patients (e.g., consistent with clinical observations of agor-
McNally & Lorenz, 1987) and nonclinical aphobics' pessimism regarding the impact of
panickers (Donnell & McNally, 1990) and to exposure despite repeated positive experiences
predict the response of nonclinical subjects to of anxiety reduction (and reluctance to continue
panic-related tasks such as hyperventilation or repeat exposure sessions), more direct
(Holloway & McNally, 1987). evaluation is required if overpredictions are to
be regarded as a key factor in the maintenance
of avoidance behavior (Rachman, 1990).
6.18.5.3.1 Panic, cognitions, and avoidance
Other direct attempts to conceptualize and
A variety of researchers have attempted to predict the relationship between avoidance
conceptualize the relationship between panic related to naturally occurring panic outside
and avoidance. Rachman has carried out an the laboratory setting, or as a factor related to
influential series of experiments in which he individual differences in anxiety responding
examines the relationship between predicted among panic patients, have met with less
fear and actual fear in subjects repeatedly success. A range of factors are weak predictors
confronting aversive events (summarized in of avoidance behavior (Craske, Rapee, &
Rachman & Bichard, 1988). The basic paradigm Barlow, 1988; Mavissakalian, 1988; Warren,
used involved asking student volunteers, pre- Zgourides, & Jones, 1989). Craske and Barlow
viously identified as claustrophobic, to repeat- (1988) review the data, and summarize the range
edly enter a very small enclosed space; in the of factors which have been found to relate to
course of experimental sessions they are asked avoidance. They note that most important
to rate anxiety and a range of other variables, identified to date are expectancy of anxiety,
particularly their expectation of anxiety prior to the extent to which patients have a predomi-
entering the enclosed space. Using this para- nantly somatic focus of anxiety, the extent to
which patients perceive panic to be related to situation are only logically possible when the
negative consequences beyond anxiety itself (as feared catastrophe has external correlates; that
in anxiety sensitivity), and access to safety is, simply leaving a situation has little value as a
signals. They attempt to synthesize this work strategy for dealing with an impending heart
within the context of Barlow's biobehavioral attack. The main ªusefulnessº of such an escape
hypothesis. However, Craske and Barlow's strategy would be in situations where social
discussion has a major limitation in the present evaluative concerns predominate; removing
context, because the approach applies only to oneself from a place where there are other
situational and expected panic attacks. The people is likely to be perceived as helpful both as
importance of spontaneous and/or unexpected direct catastrophe avoidance and as a means of
panic attacks in the origin and maintenance of removing the person from the scrutiny of others.
avoidance is stressed by most theories including As panic and avoidance become more
Barlow's own; Craske and Barlow propose no chronic, the behaviors involved probably be-
specific basis for this in their discussion, come habitual and awareness of the specific
presumably because they assume that sponta- cognitive component of avoidance will tend to
neous panic attacks are biologically determined. diminish except when directly provoked by
The cognitive hypothesis specifies that situa- deliberate of accidental exposure. Often pa-
tions which generate anxiety might become the tients express this as the desire to escape; for
focus of avoidance, but this will only become example, when asked what went through his
debilitating when accompanied by fears that the mind in a phobic situation, patients typically
anxiety might lead to other, more serious respond ªI just had to get out.º The cognition
consequences. Furthermore, the scope of motivating this wish to escape is readily revealed
avoidance could be regarded as broader than by asking what, at that time, would he have
generally encompassed by behavioral descrip- thought the worst thing that could have
tions (e.g., Marks, 1987b), with both subtle and happened should he have been unable to get
more generalized avoidance playing a major out. Thus, the cognitive analysis of avoidance
role in the maintenance of panic attacks involves an analysis of what the patient is
(Salkovskis, 1988a). For example, a patient avoiding rather than just of the anxiety arousal/
who interprets weak legs as a sign that he may relief associated with the specific situation. The
collapse attempts to prevent collapse by holding importance of the minutiae of anxiety related
on to nearby objects, tensing his legs and and safety seeking behavior also takes on a new
seeking a seat at the earliest possible opportu- importance, particularly for therapy.
nity. By doing so, he has a further effect; he The cognitive hypothesis proposes a specific
prevents disconfirmation of his fears of col- set of links, both between panic and avoidance
lapse. The patient is unaware of the anxiety and vice versa. If panic patients fear imminent
maintaining effects of his avoidant behavior disasters because of their misinterpretation of
(described here as ªsafety seekingº behavior). bodily sensations, it follows that their behavior
The effect of his behavior on his perception of should be logically related to the avoidance of
what happened is to transform an incident the feared catastrophes rather than of anxiety
which could have provided a disconfirmation of per se. This means that avoidance behavior
his fears into evidence bolstering his negative would be meaningful but idiosyncratic both to
interpretation of symptoms, in the form that he the individual and to attacks involving specific
has just experienced a ªnear miss.º The types of misinterpretations and the individual
situation would be interpreted as ªIf I had experiencing them.
not prevented it by tensing my legs, then I would Support for this view comes from a study by
certainly have collapsed.º The cognitive hy- Salkovskis, Clark, and Gelder (1996). In a
pothesis predicts an internally logical match preliminary investigation of this hypothesis,
between such beliefs and behaviors during data were collected from a questionnaire
panic; for example, fears of loss of control devised as an assessment of safety seeking
should be associated with attempts to control behaviors in panic together with assessments of
oneself. Similar considerations can be applied to some of the more common panic-related
more generalized forms of actual avoidance and cognitions in a sample of 147 panic patients.
escape behavior; an agoraphobic who decides The pattern of associations was consistent with
not to go shopping on a particular day may predictions from the safety seeking perspective.
conclude ªIt's lucky I did not go, otherwise I Holding on to an object was associated with
would have had an enormous panic; if I had fears of fainting and being paralyzed with fear.
panicked today, I would certainly have col- Holding on to or leaning on another person was
lapsed.º Once again, avoidance has ªpreventedº associated with fear of fainting. Sitting down
collapse. However, these types of behaviors was associated with fear of heart attack, acting
involving rapid ªescapeº from the immediate foolishly, and being paralyzed with fear. As
expected, keeping still was exclusively asso- distinguishes agoraphobia from problems in
ciated with fear of having a heart attack. Doing which other types of phobic avoidance pre-
more exercise was only associated with being dominate because the person does not exclu-
paralyzed with fear. Focusing attention on one's sively avoid (or endure with considerable
body was associated with thoughts of having a anxiety) situations where they are likely to be
tumor, choking to death, and having a stroke. negatively evaluated (as in social phobia) or be
The specific association with controlling one's in a confined space (as in claustrophobia) or
behavior were with thoughts of acting foolishly avoid because of some other type of anxiety
and not being able to control oneself. These (such as obsessive-compulsive disorder or post-
cognitions were also associated with trying to traumatic stress disorder). However, fear of
move more slowly, reflecting the attempt to these other types of situations may be present in
exercise control over one's behavior. The beliefs many people suffering from agoraphobia, as is it
associated with looking for an escape route are perfectly possible to experience multiple fears of
exclusively with loss of control type concerns this type.
(acting foolish, losing control, and being Such a view has the merit of considering
paralyzed with fear), and not with thoughts agoraphobic avoidance as a distinct psycholo-
concerning the more somatically-focused cata- gical phenomenon (with much in common with
strophes. This finding was expected; leaving a other types of avoidance) rather than as a
situation is a relatively ineffective remedy for symptom of some other diagnosis. According
internally located problems, where the cata- to this view, people develop a pattern of
strophe would be carried with the patient out of avoidance of particular situations because these
the situation. By contrast, the negative con- situations have become associated with un-
sequences of loss of control type events are pleasant experiences (or the expectation of
almost exclusively social evaluative. Asking unpleasant experiences). These associations
people around for help was associated with may be historical (and may therefore be
thoughts of having a heart attack and choking relatively inaccessible to introspection), or
to death, both likely to be perceived as may be more recent and vivid. This helps make
extremely serious and uncontrollable somatic sense of why panic attacks are neither necessary
catastrophes, likely to require immediate ex- nor sufficient for the experience of agorapho-
ternal aid. The pattern of associations between bia, but why there is such a strong association.
specific behaviors and cognitions found was Other types of anticipated unpleasant experi-
therefore consistent with the hypothesis that ence which can lead to an agoraphobic pattern
cognitions may ªdriveº the anxiety related of behavior include epileptic attacks, incon-
behaviors in a meaningful and idiosyncratic tinence, and irritable bowel (i.e., episodes where
way. Particular avoidant behaviors may be the person believes they are in danger of losing
occurring because they are intended by the control over their bowels). Agoraphobia can
patients as logical reactions designed to avert develop in the elderly who fear falling and
feared catastrophes. These findings are consis- breaking their bones. This way of viewing
tent with the cognitive hypothesis as a ªnormal- agoraphobic avoidance has the further advan-
izingº account of panic and associated tage of normalizing the behavior. Avoidance as
phenomena (particularly avoidant behaviors), a reaction to the perceived possibility of
highlighting the internal logic of the problem. physical or social threat is, of course, an
understandable reaction.
Within this framework, panic is the single
6.18.5.4 Agoraphobia most common factor associated with agora-
phobia. This then raises the important question
Within the cognitive framework, agorapho- of why only some people develop agoraphobia
bia is therefore regarded as motivated avoid- when they experience panic attacks. (The same
ance. In agoraphobia, the avoidance is of question clearly applies to irritable bowel
situations which involve being away from problems, epilepsy, and other associated fea-
safety, most commonly embodied by the tures; for understandable reasons research has
person's home (or other trusted helper's homes) tended to focus on the association with panic.)
and its extension by other ªsafeº objects (e.g., The second and more difficult question con-
the person's car). This does not necessarily cerns those people who have no panic or ªpanic
mean that the person is free of anxiety when at like symptomsº associated with their agora-
home, but that they feel relatively safer there phobia. There are several ways in which a
than in other situations. The fear in agorapho- tendency to avoid particular situations may
bic situations revolves around not being able to result in actual avoidance behavior. The person
leave the situation for a safer one (or not being may be particularly strongly motivated because
able to do so without embarrassment). This their fear of agoraphobic situations is especially
intense (as is usually the case when panic is baum et al., 1988). Renneberg, Chambless,
present or anticipated) or they may believe they and Gracely (1992) studied the incidence of
are particularly vulnerable to even relatively DSM-III-R Axis II personality disorders in a
small amounts of fear, perhaps because they large group of agoraphobics, and found that
underestimate their ability to cope either with 56% of the sample had at least one personality
the agoraphobic situation or their own emo- disorder, of which avoidant personality was the
tional reactions. Before a more detailed analysis single most frequent disorder. They also note
of theories of agoraphobia, clinical factors that personality disorders seem more common
thought to be meaningfully correlated with in agoraphobics than in individuals with panic
agoraphobia will be considered. disorder (see also Friedman, Shear, & Frances,
1987, and Green & Curtis, 1988)
Chambless and Goldstein (1982) report that
agoraphobic patients show low scores on the
6.18.5.4.1 Correlates of agoraphobia
Bernreuter Inventory of self-sufficiency
One view about agoraphobics which has been (although they also note that it incorporates
fairly prevalent is that they may show two basic items to do with activities to be done alone).
dispositional qualities: dependence on others, Buglass, Clarke, Henderson, Kreitman, and
and a tendency to cope with difficulties by using Fredey (1977) reported no extra premorbid
avoidance as a coping method (e.g., Andrews, dependency in agoraphobics than in a matched
1966; McGennis, Nolan, & Hartman, 1977; group of normals, but found more conflict over
Shafer, 1976). Andrews also suggests that this dependency on the mother in the agoraphobic
may be due to maternal overprotection. Math- group. They may have contaminated their
ews et al. (1981) attempted to survey the results by excluding those agoraphobics with
evidence which could be brought to bear with marked dependency. Torgesen (1979) studied a
regard to this theory. The seven studies reviewed small group of monozygotic twins of patients
present somewhat equivocal results, although with agoraphobia. He found that the agora-
several did find evidence of overprotection, phobic twin was more likely to have been
dependency, and somewhat unstable and more dependent, self-doubting, and suggestible on a
ªanomalousº families (with more adopted personality inventory, and to report having
children, etc.). Mathews et al. conclude that been like that since childhood. They were also
few properly conducted studies have been done, likely to have been the second twin, and the
but that there is some suggestive evidence of smaller one. Chambless and Goldstein (1982)
dependence as a pre-existing trait. Reich, report two other studies on assertiveness in
Noyes, and Troughton 1987) compared subjects agoraphobics. In one they found that the
who had panic disorder with varying amounts agoraphobics were less assertive than simple
of agoraphobic avoidance, and found that phobics on therapist ratings, and in the other
about 40% of subjects with some (as opposed they found that they were less assertive on
to no) phobic avoidance met criteria for assertion inventories at intake than a group of
dependent personality disorder, although it college students, and more anxious about
was not possible to determine whether the assertion. Rapee and Murrell (1988) also found
dependent behavior was primary or secondary that very avoidant individuals scored higher on
to the agoraphobia. Kleiner and Marshall the Eysenck Personality Questionnaire and
(1987) reported a high degree of dependent lower on a measure of assertiveness than
behavior in agoraphobics, prior to the onset of minimally avoidant subjects.
the phobia, and Borden and Geller (1981) in Most studies report a higher percentage of
their review suggested that dependent person- women in groups of agoraphobic patients than
ality traits are a key feature of agoraphobia. in groups with panic disorder without avoid-
There is some evidence that people who go on ance (Chambless, 1985; Wittchen, 1988), this
to develop agoraphobia may have been more has led to the stereotyped notion of the typical
fearful of being out and about in the world agoraphobic as a housebound housewife.
premorbidly. A history of school phobia is more Chambless (1985) does, however, point out
common in agoraphobics than in panic patients, that of her sample of 378 agoraphobics, 64 were
and the relatives of agoraphobics are more men and only 52% were currently married, so
likely to suffer from school phobia or agor- that this description fitted less than half of the
aphobia (Deltito, Perugi, Maremman, Mignani, patients. There has, however, been considerable
& Cassano, 1986; Gittelman-Klein & Klein, interest in the relationship between gender and
1984). There is also evidence of behavioral avoidance in patients with agoraphobia. There
inhibition (defined as a tendency to have a has been speculation that, where the roles
constricted range of exploratory behavior) in adopted are more ªtraditional,º it is easier and
agoraphobics premorbidly (e.g., see Rosen- more acceptable for women to become house-
bound than men, and for men to use alcohol as 6.18.5.5 The Cognitive Account and Research
an alternative coping strategy. The stereotypical into Panic
female gender role is also associated with traits
of dependency and unassertiveness, both found Before examining previous work specifically
to be prominent in agoraphobics. This literature designed to evaluate predictions derived from
is reviewed in detail by Chambless (1985). the cognitive hypothesis, it is first important to
A number of studies indicate that greater consider how one of the key observations
degrees of depression are associated with more thought to support a more biological view is
severe avoidance in agoraphobia (Sanderson & encompassed. The provocation of panic by
Barlow, 1986; Klosko, Shadick, Heimberg, & challenge tests such as lactate infusion and
Barlow, 1986; Telch et al., 1989; Vitaliano et al., carbon dioxide inhalation has been described as
1987). This finding was not replicated in several a ªbiological markerº for panic, in that such
other studies (e.g., Rapee & Murrell, 1988; provocations do not have the same effect on
Thyer, Himte, Curtis, Cameron, & Neese, nonpanic control subjects. Clark (1986a,1986b,
1985). Aronson and Logue (1987) reported a 1988) suggests that the research into ªbiologi-
reliable difference between PD and PDA such calº panic provocation potentially represents
that depression was more likely in individuals some of the strongest support for the cognitive
who later developed avoidance, and McNally hypothesis. As noted above, a wide range of
and Lorenz (1987) found that in a group of PDA procedures provoke panic attacks in Panic
patients depression predicted a resurgence of Disorder patients but not in control subjects,
avoidance. The association between depression although the procedures concerned have no
and avoidance may be conceptualized within identifiable common biochemical or physiolo-
the theoretical framework of learned help- gical basis, making it difficult to envisage any
lessness and attributional style, if it is found specific biological mechanism. They do, how-
that PD patients with avoidance have weaker ever, have a common psychophysiological
beliefs in their own ability to cope with stress. feature relevant to the cognitive hypothesis,
Klosko et al. (1986), who showed that panic which is that all of these substances induce a
disorder patients with avoidance were more range of intense physical sensations in all
likely to attribute negative events to stable and subjects, panic or otherwise. Thus, the tendency
global factors, and Telch et al. (1989) showed to panic under such diverse provocations is
that panic disorder patients with avoidance consistent with the hypothesis that panic arises
were likely to rate their ability to cope with from the misinterpretation of bodily sensations.
panic as lower than patients with panic disorder For example, it may be that panic patients
without avoidance. interpret the effects of panic-inducing proce-
Several studies indicate that there is very little dures as a sign of some kind of adverse reaction
difference between the thoughts of possible in their body to the inductions, all of which
physical consequences of bodily sensations (or involve some kind of unusual physical proce-
in the extent to which they fear them) in people dure. To test this possibility, a number of
suffering from panic with agoraphobia as researchers have carried out experiments into
opposed to panic patients with minimal avoid- psychological factors affecting biological in-
ance. The main difference observed is a greater ductions.
fear of dizziness, and a higher frequency and In a particularly elegant experiment, Sander-
belief in thoughts of fainting among the son, Rapee, and Barlow (1989) demonstrated
agoraphobics (Salkovskis, 1990; Telch et al., that the effects of carbon dioxide inhalation are
1989). In the study by Telch et al., the more modified if panic patients believe that they can
avoidant group showed much higher scores on control the inhalation by switching it off. In the
scales reflecting fears of loss of mental control, experiment, the button which was supposed to
or social ridicule. These results echo those of turn off the carbon dioxide was not, in fact,
other studies which have found that agorapho- connected, so the fact that only two patients out
bics tend to have more social evaluative of the 10 in the perceived control condition
concerns than patients with panic disorder (de panicked as compared to eight of 10 patients in
Ruiter & Garssen, 1989). In the study by Telch the comparison group is attributable to the
et al., agoraphobics were found to have less illusion of control. In an experiment in which
perceived self-efficacy relating to dealing with hyperventilation was used as a provocation, the
panic than other panic patients. Hoffart (1995) effect of hyperventilation was compared in
has also shown that low scores on a measure of panic patients and patients having a diagnosis
perceived self-efficacy predict situational avoid- as general anxiety disorder (Rapee, 1986). In
ance more strongly than other measures, this study, panic patients recognized the effects
including a measure of catastrophic beliefs of hyperventilation as very similar to their
about the symptoms of panic. experience during panic attacks, while patients
suffering from generalized anxiety disorder did associated with an increased perception of
not. However, none of the 20 panic patients bodily or ªmentalº sensations. For example,
actually experienced a full attack, and the it seems likely that there may be a genetic
degree of similarity between hyperventilation component to emotionality, which may make
and panic was highly variable. This result can be particular individuals prone to experiencing
readily accounted for by the cognitive hypoth- relatively intense reactions to threat. Indeed,
esis, because in this experiment the patients will such an observation would be quite consistent
have a clear explanation of why symptoms are with the cognitive hypothesis. For example, if
occurring, so that they are unlikely to mis- there was an identifiable subgroup of subjects
interpret their sensations catastrophically, par- who were particularly likely to experience
ticularly as the provoking ªagentº is a readily intense and apparently inexplicable physiologi-
controllable behavior (breathing quickly and cal sensations, it is quite likely that such subjects
deeply). The absence of anxiety-provoking would be predisposed to panic. However,
thoughts noted during the experiment would without the element of catastrophic misinter-
also have had the effect of minimizing the pretations, such individual differences would be
autonomic arousal which normally occurs at the insufficient to account for panic attacks.
same time as symptoms of hyperventilation Indeed, many people actively seek out circum-
during normally occurring panic, reducing the stances in which they are likely to experience
perception of similarity. heightened levels of arousal (e.g., horror films,
Another experiment from the same labora- exciting sports). This point is illustrated by the
tory (Rapee, Mattick, & Murrel, 1986) manipu- example of hyperventilation, which presents
lated cognitive factors prior to 50% CO2/50% some problems of classification briefly dis-
O2 inhalations, a procedure which has been cussed above, where it was concluded that
shown to induce panic attacks in panic patients although hyperventilation was neither neces-
but not in normal controls. In this experiment, sary nor sufficient to account for panic, the data
subjects were either given a full account of the concerning the relationship between hyperven-
effects of the inhalation or given only minimal tilation and panic strongly suggested some kind
instructions. Panic patients who were not given of link.
the full explanation perceived the effects of the
inhalation as more similar to panic and
6.18.5.6.1 The cognitive link between panic and
experienced more catastrophic cognitions than
hyperventilation-induced symptoms
patients who were given an account of the
effects. Groups of social phobics compared on As described above there are a range of
the same basis showed no effect of instructions, findings which strongly suggest that hyperven-
demonstrating the specificity of this finding to tilation may be involved in some way in panic
panic patients as opposed to other anxious attacks. However, the hyperventilation hypoth-
patients. esis of Ley and others is not well supported by
Recently, an experiment has been carried out the experimental evidence. The association
with the most important of these substances, between panic and hyperventilation can best
sodium lactate; Clark et al. (in preparation) be accounted for by the cognitive hypothesis of
demonstrated that, if patients are given detailed panic, the early development of which was
information which prevents misinterpretation intimately connected with interest in the role of
of the symptoms of the infusion, panic is hyperventilation in the physical symptoms
blocked. Thus, the cognitive hypothesis pro- experienced by some patients (Clark & Helms-
vides a testable account of the effects of so- ley, 1982; Salkovskis, 1988a, 1988b).
called biological panic provocation tests, and The way in which the cognitive hypothesis
this account has already received some support can account for the apparently conflicting data
from experimental investigations of the me- concerning the link between panic and hyper-
chanisms involved. ventilation is illustrated in Figure 2, which is a
specific development of Figure 1. Although in
his schema for the link between hyperventila-
6.18.5.6 The Relevance of Psychobiological tion and panic, triggering sensations may
Factors to the Cognitive Hypothesis sometimes arise from hyperventilation, this is
of Panic not in any sense required in the way demanded
by Ley (1985a, 1985b) (cf. Hibbert & Pilsbury,
The cognitive model does not rule out the 1989). Upsetting thoughts, images, and situa-
possibility that some Panic Disorder patients tions which have previously been associated
may be physiologically more vulnerable to with panic are probably more likely to serve as
episodes of panic, for instance because of triggers (Clark, 1988). The perception of threat
biological differences in autonomic lability results in apprehension, which in turn results in
arousal and, in some instances, hyperventila- the sensations are misinterpreted in a cata-
tion. If (and only if) the bodily sensations which strophic fashion, then hyperventilation-induced
then occur are interpreted as a sign of imminent sensations can then also become a ªcauseº of
personal harm of internal origin, then anxiety stress as part of the cognitive mechanism
and bodily sensations are likely to show a described above (Salkovskis & Clark, 1986).
further and sudden increase which will in turn Increases in respiration are a normal part of the
be catastrophically misinterpreted, and so on stress response and can occur without aware-
round in a vicious circle culminating in a panic ness, probably making misattribution more
attack. likely in vulnerable individuals.
There are several additional points which Even in instances where hyperventilation
emerge from this analysis. It is proposed that does occur during a panic attack, note that
stress induced hyperventilation can be a source the anxiety arising from the catastrophic
of intense and frightening bodily sensations, misinterpretation of hyperventilation-induced
although such sensations are not intrinsically bodily sensations is very likely to be accom-
either unpleasant or frightening (Clark & panied by autonomic arousal in addition to the
Helmsley, 1982). Thus, hyperventilation can effects of hyperventilation. This means that,
be an effect of anxiety and stress; if and only if even in panic attacks in which hyperventilation
Trigger
(perceived bodily sensations,
catastrophe related thoughts,
situation previously associated with panic)
Perception of imminent or
present threat
Apprehension
Interpretation of
Autonomic
sensations
nervous
as catastrophic
system arousal
Attempts to
increase
respiration
Hyperventilation
Perceived
Bodily and/or breathlessness
mental sensations
Figure 2 The principal components of the cognitive model applying to panic attacks in which hyperventilation
is involved in the production of symptoms.
Evaluating the Cognitive Hypothesis 423
is involved, many of the sensations which occur concluded that the evidence is consistent with
may not be due to the effects of the respiratory the view that hyperventilation can play an
alkalosis alone, making the importance of the important role in the maintenance of panic in
effects of hyperventilation more difficult to some individuals, but that it is neither necessary
determine. or sufficient. The symptoms of hyperventilation
There are several reasons why hyperventila- will only be involved in the mechanism of panic
tion is a particularly powerful mechanism for the to the extent that they subject to specific
production of sensations which are subsequently catastrophic misinterpretations.
misinterpreted. Hyperventilation can produce a Consistent with such a cognitive view is the
wide range of sensations very quickly. Some of data from a study by Salkovskis and Clark
the sensations produced by hyperventilation are (1990). Neurobiological hypotheses regard
often unfamiliar even to patients who have localized (brainstem) effects of pH changes
previously experienced intense anxiety in spe- (particularly secondary to respiratory alkalosis;
cific situations (e.g., parasthesias, dyspnea, Liebowitz et al., 1986) as being the basis of acute
tetany), as is the sudden onset and rapid increase panic attacks. Hyperventilation-based theories
of symptoms. When dyspnea is associated with (Fried, 1987; Ley, 1985a, 1985b; Lum, 1976)
panic, as is often the case (Pollard, 1986), this also regard the aversive effects of respiratory
may be misinterpreted as a sign that breathing is alkalosis to be central to the experience of panic.
about to stop. This specific misinterpretation In both instances, hyperventilation is regarded
increases the likelihood that patients will as a biologically-based panic induction proce-
respond to sensations by a deliberate increase dure. On the other hand, the cognitive hypoth-
in their breathing (Bass & Gardener, 1985), esis specifies that hyperventilation is not
which will in turn have the effect of further intrinsically aversive, and that the affect
intensifying sensations. Patients often report experienced will be a function of the way
taking ªdeep breathsº in an attempt to calm symptoms are interpreted. If this is so, this
themselves down when anxious. Such behavior would also be further evidence that hyperventi-
is particularly associated with misinterpretation lation is neither necessary nor sufficient for the
of breathlessness as a sign of imminent cessation experience of panic, and highlights the intrinsic
of breathing. This means that, for some patients, weakness of unmodified breathing control
panic associated hyperventilation might be exercises as a means of treating panic. Salkovs-
entirely determined by voluntary effort directed kis and Clark (1990) experimentally manipu-
at the prevention of suffocation. lated the way in which symptoms of
Finally, there is evidence that repeated hyperventilation were interpreted. Nonclinical
episodes of hyperventilation over a longer subjects were provided with a relatively positive
period can result in a change in the buffer set or relatively negative interpretation of the
point as renal excretion of bicarbonate com- effects of hyperventilation, and the results
pensates for respiratory alkalosis of longer evaluated both in terms of subjective and
durations, as happens in altitude adaptation physiological responses. Those given a positive
(Okel & Hurst, 1961). This adaptation has the interpretation responded to the sensations as
effect of lowering resting paCO2 levels and pleasant, while those given a negative inter-
increasing the sensitivity of the buffer system to pretation found them aversive. Furthermore,
challenge. That is, low resting paCO2 does not affect was strongly correlated with the intensity
itself produce symptoms, but small changes in of bodily sensations experienced, but only the
CO2 (such as are associated with exercise or affect congruent with the interpretation given.
mild stress) produce relatively greater increases
in respiration. This phenomenon will also have
cognitive effects, as patients notice their 6.18.6 EVALUATING THE COGNITIVE
increased sensitivity, and interpret this as HYPOTHESIS
further evidence for their belief that panic
attacks are signs of a serious illness or harm. Clark et al. (1988) enumerated predictions
Although several studies have demonstrated directly arising from the cognitive hypothesis of
that the resting paCO2 levels of panic patients panic disorder. Experimental studies have
are significantly lower than those of normal evaluated the cognitive account of laboratory-
controls, the only well-conducted study to based biochemical panic inductions (Clark,
examine the study of central CO2 regulation 1993) and the presence of catastrophic mis-
failed to find any evidence of increased interpretations of bodily sensations, both as an
sensitivity (Woods et al., 1986). (This negative enduring characteristic of patients suffering
finding might be accounted for by the fact that from Panic Disorder and as a more acute
panic patients did not differ from controls in phenomenon occurring during panic attacks
resting level of paCO2.) Thus, it can be themselves (reviewed in Salkovskis, 1989).
Chambless and Gracely (1989) evaluated the options, which include two neutral interpreta-
cognitions of patients with diagnoses of Panic tions and one negative or catastrophic option.
Disorder, Agoraphobia with Panic, Generalized For example, an item might be
Anxiety Disorder, Social Phobia, Obsessive-
Compulsive Disorder, and Depression. They You notice your heart is beating quickly and
found that Agoraphobics scored higher than all pounding.
other groups on fear of physical sensations; Why?
both Agoraphobics and Panic Disorder patients and offer the options:
scored higher than all other groups on thoughts
that physical harm would result from their Because you have been exercising
anxiety. They also found that, in Agoraphobics, Because there is something wrong with your heart
fear of bodily sensations and agoraphobic Because you are excited
thoughts (i.e, catastrophic cognitions) predicted
self-reported avoidance behavior even when the Panic patients were found to score higher than
effects of trait anxiety were statistically re- controls not only on internal (body sensation)
moved. Similar results were found by Hout van items, but also on external threat situations.
den, van der Molen, Griez, and Lousberg However, direct examination of Foa's version
(1987) for fear of bodily sensations in Panic of the questionnaire reveals a specific problem,
Disorder patients, who were significantly dif- which is that there is confusion between nega-
ferent from nonpanic ªneuroticº patients and tive interpretations per se and panic-related
normal controls. responses. Thus, many of the ªnegativeº choices
Rachman and Levitt (1985) tested claustro- offered are ªBecause you are about to panicº or
phobic subjects, who were asked to enter a very ªBecause you are very anxious.º In the same
small confined space (a ªclosetº). They demon- paper, Foa presents laboratory data from an
strated that, in subjects experiencing a panic otherwise unpublished experiment by Mansue-
attack in this situation, breathlessness was to, Grayson, and Foa on the subjective and
particularly associated with thoughts of suffo- physiological responses to imagery of internal
cation. Furthermore, they found an association and external fear stimuli. The results show that
between failure to habituate to repeated ex- agoraphobic patients show significantly ele-
posure and the specific presence of thoughts of vated subjective anxiety and heart rate re-
suffocation, as they had predicted from a sponses to imagery of external fear situations,
cognitive analysis based on the misinterpreta- imagery of autonomic fear responses alone, and
tion hypothesis. the two combined compared with neutral
McNally and Foa (1987) and Dattilio and imagery. Specific phobics showed a similar
Foa (1987) (described in Foa, 1988) used pattern, except that imagery of autonomic fear
variants of questionnaires employed by Butler responses alone was not different from neutral
and Mathews (1983). The questionnaires were imagery. However, the analysis presented is
intended to tap two main phenomena: solely within-group; Foa does not specify
(i) The subjective probability and perceived whether the groups differed on this item (i.e.,
aversiveness of bodily sensations, in which whether there was a significant group X con-
subjects rate the likelihood of occurrence of dition interaction). Inspection of means pro-
interoceptive sensations and externally-based vided suggests that there may not have been.
fear situations, together with judgments of how In a study based on the McNally and Foa
aversive such occurrences would be. Although (1987) experiment described above, but de-
the results show elevated subjective probabil- signed more specifically to evaluate the cogni-
ities and cost in panic groups compared to tive hypothesis, Clark et al. (1997) used a further
anxious controls for interoceptive stimuli and variant of the Butler and Mathews (1983)
not external fear situations, the results for this questionnaire in order to evaluate the tendency
questionnaire are difficult to interpret because to misinterpret bodily sensations. This study
the actual probabilities for the experience of found that panic patients were significantly
interoceptive (i.e., panic) symptoms are, by more likely to misinterpret physical sensations
definition, likely to be considerably higher for associated with panic than other anxious
the panic patients. patients who did not have panic attacks, but
(ii) The interpretations which might be made were no more likely than other anxious patients
of vignettes concerning interoceptive or exter- to misinterpret general and social situations.
nal stimuli (McNally & Foa, 1987). This ques- The results of questionnaire studies of this
tionnaire provides the subject with a range of kind are often criticized because it may be that
imaginary scenarios and asks the subject what patients are aware of how they are expected to
they think is happening in the specified situa- respond. In a study designed to evaluate the
tion. Subjects respond by endorsing one of three interpretation question without possible sub-
Treatment 425
jective biases, a technique called Contextual ingly, no panic attacks occurred when the paired
Priming was used (Clark et al., 1988). This associates task was carried out with a group of
technique, derived from psycholinguistics, is panic patients who had been successfully treated
intended to determine subject's expectations of by cognitive therapy.
particular meanings as provided by specific A range of other experimental investigations
contextual cues. An incomplete sentence is has now been completed by the Oxford group
projected on a computer screen; for example, and others. The cognitive model has been able
ªThe cat drank the . . .º. The sentence fades, and to explain findings from the biological field
a word replaces it; the person watching simply (e.g., how biological challenges such sodium
has to say the word as quickly as possible, and lactate provoke panic) and experimentally test
the subject's reaction time is measured using a these findings (Clark, 1993). On the other hand,
voice key triggered by the subject's verbal biological theorists have been unable to account
response. Subjects are faster at naming the final for findings in the cognitive field. Many specific
word when the word makes a relatively expected predictions arising from biological research
completion compared to relatively unexpected have been falsified; for example, Gorman et al.
completions. In the above example, subjects (1989) predict that psychological treatments will
would be appreciably quicker with the word not reduce anxiety, but will only have effects on
ªmilkº than the word ªvodka,º revealing avoidance.
something about the person's belief about cats'
drinking habits. In the experiment with panic
patients, the incomplete sentences included 6.18.7 TREATMENT
items such as ªMy heart is beating quickly
An important clinical prediction from the
and pounding because I am . . . º. Two possible
cognitive hypothesis is that interventions which
completions were used for this sentence: ªdy-
result in an enduring modification of cata-
ingº or ªexcited.º Consistent with the cognitive
strophic misinterpretations made by panic
theory, panic patients were significantly faster
patients should result in clinically significant
when catastrophic completions were presented
improvements in panic. It is important to note
(e.g., the word ªdyingº in the above example),
that the effectiveness of treatment does not
while controls did not show this difference. This
provide any conclusive evidence for the hypoth-
suggests that panic patients have specific
esis upon which it is based. However, ineffec-
negative beliefs, and that such misinterpreta-
tiveness of treatment based on the hypothesis
tions can be rapid and automatic.
would present considerable problems (Gorman
Although the demonstration that panic
et al., 1989; Teasdale, 1988). Cognitive treat-
patients specifically misinterpret bodily sensa-
ment now emphasizes two major components:
tions, it could still be argued that these patients
(i) strategies designed to help patients to change
show such misinterpretations because they are
misinterpretations of bodily sensations as they
experiencing panic attacks rather than vice
occur during panic attacks, and (ii) modifying
versa. More convincing and less ambiguous
the beliefs upon which such catastrophic
evidence for the theory comes from the
misinterpretations are based.
prediction that activating misinterpretations
should make panic patients (but not anxious
controls) experience panic-like states. The task 6.18.7.1 The Theoretical Roots of Treatment
which was devised to do this was a simple word-
reading task, where subjects were asked to read Both testable theoretical refinements (such as
words such as the importance of safety-seeking behavior as
breathlessness-suffocate described above) and experimental studies can
palpitations-heart attack make contributions to the refinement of treat-
unreality-insane ment techniques and strategies. The way that
slowly, as pairs, pausing to dwell on each pair. these examples have had an impact on treatment
Seventy-five percent of the panic patients asked will be described next.
to do this experienced a panic attack (as defined Some of the most important implications of
by DSM-III, viz., experiencing an increase of at the cognition-behavior links described above
least four physical symptoms and a sudden concern treatment (Salkovskis, 1991). In gen-
increase in anxiety), as opposed to 17% of eral, cognitive-behavioral treatment emphasizes
anxious controls and no nonclinical controls. the need to deal with idiosyncratic factors which
Another stressful task (backwards serial sevens) bolster the continued misinterpretation of
did not differentiate panic patients from bodily sensations. For example, a patient who
anxious controls; although anxiety increased became confused during panic describes men-
substantially in both groups, none of the tally ªholding on to my sanity.º In each
subjects experienced a panic attack. Interest- successive panic he becomes more convinced
that he would have gone mad were it not for this be directly relevant to the specific experience of
effort. Another example is the patient who, anxiety. The particular strategy of using
hundreds of very severe panic attacks later, still exposure as an exercise in testing alternative
believes in each new attack that she is about to nonthreatening interpretations of experience
go crazy, pass out, or die. Clinically, question- would be predicted to succeed better than brief
ing of such patients reveals that no disconfirma- exposure with ªsupplementaryº (threat-irrele-
tion has occurred because the patients believe vant) cognitive change procedures. That is, such
that they have, in every instance, been able to a study should show that ªgeneralº cognitive
take successful preventative action. Thus, each therapy combined with exposure has an additive
panic is a near miss and further confirmation of effect, while ªanxiety-focusedº cognitive ther-
the risk. Once such behavioral responses are apy would be expected to multiply the effect of
identified, the patient can be helped to begin the exposure, resulting in maximal cognitive change
process of reappraisal by withholding such through behavioral experiments. Thus, accord-
protective responses and learning the true extent ing to the cognitive hypothesis, the value of
of risk. Typically, this may involve suggesting to behavioral experiments transcends mere expo-
the patient that they challenge their worries by sure; such experiments allow patient and
actively trying to cause the feared disaster, for therapist to collaborate in the gathering of
example, going into the supermarket and trying new information assessing the validity of
to faint or try to go mad. This helps the patient nonthreatening explanations of anxiety and
to discover that their efforts to prevent these associated symptoms. (Findings consistent with
disasters have been misdirected; this can also this hypothesis have been found in Social
help the patient to then reinterpret their usually Phobia by Wells, Clark, Salkovskis, Ludgate
considerable past experiences of such anxiety- et al. (1995) and in Panic Disorder with
provoking situations as true disconfirmations Agoraphobia by Salkovskis et al. (1998).)
instead of ªnear misses.º This particular type of Since devising the paired associates task
association might be a fruitful one for investiga- described above as an experimental task for
tion, as controlling one's mind is a common use in the laboratory, we have found that it is a
response in panic patients as well as other particularly effective strategy as part of treat-
groups, including nonclinical subjects. Given ment. Given that cognitive therapy involves a
the readiness with which patients can reproduce process of reattribution in which the panic
this type of behavior as either safety-seeking or sufferer is helped to understand that the
coping when requested in the laboratory, symptoms which they experience do not arise
experiments concerning the use of the same from the feared catastrophes, the most effective
degree of effort directed at different targets (i.e., way of doing this is to provide the person with an
reduction of anxiety vs. preservation of sanity) alternative, noncatastrophic explanation (the
could be used to assess the validity of the personalized vicious circle model). The paired
cognitive basis of such behavior and its putative associates can be a particularly powerful way of
anxiety-preserving effects when used as a safety- convincing the sufferer of the validity of the
seeking behavior. A further implication is that vicious circle model. A personalized version of
for the most complete and enduring treatment the paired associates is used (derived from a
effects, controlling panic should not be empha- careful assessment of the symptoms experienced
sized. Helping people to change their beliefs and the misinterpretations made by that person).
about the meaning of their symptoms in a more If the person begins to panic, they are asked what
enduring way is the target, and should reduce they make of the experience. If reading these
subsequent vigilance and preoccupation. particular pairs of words can induce panic, how
The present analysis also suggests ways of does that fit with the idea that your symptoms
combining cognitive procedures and brief mean that you are having a heart attack? How
exposure in a way which should be particularly does this fit with the vicious circle explanation?
effective in bringing about belief change without We have also discovered, in the context of
repeated and prolonged exposure being neces- therapy, that quite simple strategies will readily
sary. Thus, exposure sessions are devised in the modify panic patients' response to the task. For
manner of behavioral experiments, intended as example, a patient undergoing therapy was
an information gathering exercise directed concerned that her initial panic when reading
towards invalidation of threat-related interpre- the paired associates meant that she was so out
tations. Most previous studies in which cogni- of control that even reading words on a card
tive and behavioral treatments have been could make her have a panic. She was asked to
combined (such as those reviewed in Marks, read the same card, but where the hyphen
1987a, 1987b) have used cognitive procedures as appeared in the pair (e.g., breathless-suffocate)
a way of dealing with general and ªback- she was to say ªdoes not mean I will.º This
groundº life stresses, most of which tend not to procedure completely abolished her anxious
Treatment 427
response to the card. When asked what she had emphasis by some on ªcorrect breathing,º by
learned, she replied that she now understood others on ªpositive thinkingº). In order to
that changing the meaning of panic symptoms ensure therapy integrity, therapy evaluations
was the key to dealing with panic attacks, and need to combine assessment of specific techni-
that she did not need to exercise control over ques with the evaluation of therapy style and
panic. This clinical illustration shows both the quality of relationship. Other factors which are
potential strengths of the technique and the of key importance (and which need to be
dangers of its uncritical use. equated across any more refined comparisons of
different therapies) are therapist time, the initial
credibility and expectation of improvement
6.18.7.1.1 Cognitive therapy for panic: some
engendered by the different treatments prior
general issues
to any differential treatment effects, any
Cognitive therapy has similar prerequisites to assessments and self-monitoring, and so on.
other forms of psychological treatment; primary
among these is the formation of a good,
6.18.7.1.2 Clinical implementation of cognitive-
collaborative therapeutic relationship. The style
behavioral therapy
of therapy emphasizes guided discovery, so that
the patient is helped to understand and try to Once it has been established that panic is a
modify their problems by using careful ques- major problem for the person and a more
tioning. Therapy also makes extensive use of general assessment of the patient's situation has
diaries and other aids; a particularly helpful been carried out, a specific panic-oriented
adjunct to the most efficient use of treatment assessment is undertaken. This assessment
time is to tape record therapy sessions so the focuses on eliciting an account of recent panic
patient can listen to the tape at home. These attacks and devising an individualized vicious
elements are considered to be a minimum circle explanation of the sequence of events
baseline against which any effective therapy during panic (loosely based on Figure 1, but
needs to be judged. The general cognitive theory always tailored to the idiosyncratic description
predicts that specific techniques will be of of the patient). The links which comprise the
minimal effectiveness in the absence of a good vicious circle should be elicited by systematic
therapeutic relationship as described above. Part questioning, thus ensuring both that the
of this relationship involves a proper assessment assessment is accurate and that the patient is
of the idiosyncratic problems experienced by the clear about the way in which the formulation
person in their own unique individual context. has been reached. The patient has to recall the
Therapy is based on the view that if a person last major panic they experienced, and then to
holds a ªdistortedº belief, this is because they describe, step by step, how it developed.
have good present, contextual, and historical Questioning is guided by use of the sequence
reasons for doing so. This is equally true not only in the upper part of Figure 3, leading to the
in the obvious case of general feelings of low self- construction of a vicious circle as shown the
worth in a person whose main difficulty is low lower part of the figure. Thus, if the first thing
self-esteem, but also for specific misinterpreta- the patient noticed was a physical sensation, the
tions of bodily sensations in someone suffering next question should concern the way the
from frequent panic attacks. For example, it is patient interpreted it (e.g., ªWhen you noticed
often important not only to pinpoint just what your heart pounding, what went through your
the person means by the idea of losing control, mind at that time?º). Another question which
but also loss of control is a major issue for them. may be useful at this crucial stage in the
Most commonly, these types of concern reflect assessment is ªRight then, at that time, what did
ªdevelopmentalº issues. you think was the worst thing that could
Evaluation of specific techniques or strategies happen?º Once a specific catastrophic thought
must therefore take place against the necessary (or image) is elicited, questioning shifts to the
background of good and consistent general anxiety experienced (e.g., ªWhen you had the
therapeutic skills. People (clients and therapists) thought, ªI'm having a heart attack,' how did
seldom work well with those who they tend to that make you feel?º). The next question
distrust. Many of the negative findings in the concerns physical reactions to anxiety (e.g.,
field can be explained not only by the failure of ªwhen you became anxious about having a
the specific intended manipulation (which is, of heart attack, how did that affect you physi-
course, a fatal error) but also by inappropriate cally?º). Once the vicious circle has been elicited
therapy styles. One of the most common errors in this way, it is summarized verbally and
in this respect is the use of cognitive-behavioral outlined on paper for the patient. Thus, in the
treatments in a prescriptive fashion. Another above example, the summary would go: ªLet's
example is to abstract a single element (e.g., the see if I have understood what you are telling me.
During the attack you experienced on Wednes- Discussion involves helping the patient to
day night, you first noticed your heart pound- evaluate such evidence and consider alterna-
ing. You then had the thought Ì'm having a tives. For example, assessment of a patient
heart attack,' and this, not surprisingly, frigh- revealed that, during panic, she interpreted
tened you. The anxiety made your heart pound dizziness, unsteadiness, and feelings of unreality
more, which seemed to confirm the idea that as a sign that she was about to faint or collapse.
you were having a heart attack, and so on, Attacks invariably started with an episode of
round in a vicious circle as I've drawn here. dizziness, often triggered by postural change or
Does that seem to you to be right?º In this way, feeling angry and frustrated. The evidence for
a positive description of the factors involved in her belief that she would faint was that the
the production of panic is built up from symptoms, especially faintness, became very
information provided by the patient. Note that intense when she was at the height of an attack,
the emphasis is on providing a positive, and that she had, on a previous occasion,
noncatastrophic account of panic rather than fainted. During the first stage of this discussion,
on disproving feared catastrophes. The internal the patient and therapist went over the factors
logic of panic is emphasized as a way of involved in a true faint, and agreed that a drop in
normalizing the intensity of the anxiety experi- blood pressure was required in order to faint.
enced (e.g., ªHow do you think that anyone The patient, when asked what she thought might
would feel if they noticed that they were feeling happen to her blood pressure during panic, said
dizzy and believed that this meant they were that she knew that it went up a little and this
about to faint? . . . When someone becomes therefore must mean that she could not faint
anxious because they have a very frightening during panic. The discussion then moved on to
thought, such as about having a heart attack, her previous fainting episode, which had
how do you think they would feel physically?º). occurred after giving blood. The reasons for
A helpful pointer for the assessment, and a blood pressure drop in this specific situation
further illustration of the logic of panic, is the were discussed. The patient was also asked to
way in which catastrophic interpretations tend compare the experience of fainting with the
to be meaningfully associated with particular experience of feeling faint in panic; she identified
symptoms. Examples of the way in which this these as quite different. In particular, she noted
association works are illustrated in Table 2. that when she fainted she was not anxious, but
Assessment as described above is the first instead became rather sleepy and distant. When
component of treatment, because it already asked whether that distant feeling resembled the
involves a major element of decatastrophizing, unreality she experienced during panic, she said
helping patients to make sense of the panics that it was quite different, and summarized by
which had previously been especially frighten- saying that she would easily recognize a true
ing because they appeared to be inexplicable. faint if it were to occur, and that fainting was
The procedures used for further decatastrophiz- particularly unlikely during panic attacks. This
ing are divided into verbal techniques, in which was an especially useful manoever, because it
discussion of the patients' past experience is meant that previously anxiety-provoking situa-
used to change beliefs and behavioral experi- tions had now become safety signals. Following
ments, in which the patient and therapist devise on from this, the discussion moved on to
experiments to test the way in which particular consideration of the nature of ªfeeling faint,º
processes may be involved in panic attacks. and whether such feelings were necessarily
(i) Discussion. The vicious circle model is associated with the fact of fainting. The
again the starting point for discussion aimed at comparison with having a splitting headache
helping the patient to attribute the symptoms was used; did a splitting headache mean that
they experience during panic away from one's head could split? The patient agreed that
catastrophic explanations and on to less this was unlikely and her ratings of belief in the
threatening interpretations. The therapist starts idea that she might faint during a panic attack
from the assumption that, if the patient makes dropped substantially, but not completely.
catastrophic interpretations, they do so because When questioned about the basis of her beliefs,
they have evidence which they find convincing. she said that the symptoms were so intense at the
This evidence may be past experiences (e.g., a time she believed that there had to be something
close relative or friend who experienced similar wrong that could lead her to faint. The therapist
symptoms associated with serious illness), in then asked her if she had been excited recently.
generalized attitudes (e.g., ªIf I can't control my She said that she had. Three weeks previously,
thoughts I will go madº), in the intensity or she had thought that she had won a very large
nature of the physical sensations themselves sum of money (on the football pools). She
(e.g., ªI feel so faint that I must be about to pass described her bodily sensations at that time,
outº), and so on. which were almost identical in type and intensity
Treatment 429
. . . Symptom Interpretation Emotion Symptom Interpretation . . .
Symptom
Emotion Interpretation
Figure 3 Construction of a vicious circle.
to those she experienced during a panic, ness, and so on; these symptoms are a
although she had not panicked and found the particularly potent basis of misinterpretation
experience pleasurable and exciting. Careful because they are often relatively unfamiliar to
questioning elicited the main difference to be the the patient in the context of his or her previous
way in which she interpreted the sensations of experience of anxiety (e.g., paresthesia and
excitement; she had not had any catastrophic dizziness).
thoughts. The conclusion she drew from this Particularly common is the experience of
discussion was that the symptoms she experi- breathlessness, which, if misinterpreted as a sign
enced during panic attacks were the normal of impending suffocation, can have the effect of
effects of adrenaline, and not a sign of something making the patient try to breathe more,
physically amiss. Finally, ways in which the worsening the breathlessness, and so on. An
patient could apply the reasoning outlined above especially helpful way of dealing with this is to
during panic attacks were devised and discussed. ask the patient to show how he or she breathes
(ii) Behavioral experiments. Discussion in (or tries to breathe) at the height of a panic
which the evidence upon which patients base attack. If the pattern the patient demonstrates
their catastrophic misinterpretations is reviewed appears to involve an element of hyperventila-
continues throughout therapy. However, pation, the therapist asks the patient to continue to
tients sometimes do not have ready access to breathe in the same way (or, if it is only a slight
information which would help them to chal- degree of hyperventilation, to exaggerate this)
lenge their misinterpretations, or understand for a few minutes, then to describe the physical
the alternative explanations which have been feelings they experience. This type of procedure
generated in the course of discussion but require reproduces the bodily sensations experienced
further evidence to support the alternative. This during a panic attack by about 50%; the fact that
is where behavioral experiments are particularly the patient is simply doing what they would
valuable as part of treatment. A wide range of normally be doing during a panic makes this
behavioral experiments are useful. One of the demonstration of the role of hyperventilation
most commonly used involves the use of particularly convincing to him or her. Discus-
hyperventilation, which often occurs in associa- sion of the extent to which the experience of
tion with panic when the associated symptoms deliberate overbreathing was similar or different
are misinterpreted. The metabolic alkalosis from the patient's naturally occurring panic will
which accompanies hyperventilation produces usually show that the physical sensations were
a wide range of physical symptoms, such as similar, but the experience differed in the extent
tachycardia, dizziness, paresthesia, breathless- to which anxiety was present. This, of course, is
because the patient in the therapist's office has an have the effect of maintaining the panic-related
unambiguous and nonthreatening explanation beliefs; the patients logically infer that they have
of their symptoms, and because the patient is in prevented the occurrence of feared catastrophes
control of the onset (and therefore the offset) of by their behavior (e.g., ªIf I had gone to the
the symptoms themselves. This difference can supermarket yesterday, then I would have
itself help pinpoint the crucial role of misinter- passed out; If I had not left immediately I
pretations; thus, the patient is taught that would have fainted; If I had not sat down then I
hyperventilation does not cause panic, but is a would have fainted.º Thus, behavior of the type
likely source of symptoms which can be described above prevents disconfirmation of the
misinterpreted. Subsequently, patients may find feared catastrophes, and transforms potential
it helpful to learn simple breathing control disconfirmations into ªnear misses.º In cogni-
techniques which they can use during panic tive therapy for panic, patients are helped to
attacks as part of the general cognitive strategy. understand how their behavior can maintain
It is important to stress that breathing control is anxiety (in the same way as outlined above), and
a helpful way of dealing with the nuisance value the therapist helps the patient to use this
of symptoms, but only at times when the patient information to construct an explanation of
notices the physical symptoms. It emphasizes the persistence of their beliefs. For example, a
that the control of breathing is in no way patient summarized this as ªAlthough I believe
essential; indeed, in the later stages of therapy the that my behavior has prevented disaster, maybe
patient deliberately hyperventilates in situations this is only because I have never tried to check
which tend to make them anxious; this exercise this out, and have just assumed that my not
provides further confirmation of the noncatas- fainting was because of the precautions I took.
trophic nature of bodily sensations. Through- By continuing to behave as if I might have a
out, the emphasis is on the idea that the key heart attack might have kept my anxiety going,
factor is misinterpretation; breathing control is because it was a constant reminder that I have to
most useful as evidence for a noncatastrophic be careful, that I am vulnerable. I have never
interpretation of the symptoms. During an acute given myself the opportunity to test the truth of
attack, the patient reminds him- or herself (a) my fears.º The therapist uses the patient's
that the physical symptoms of panic were understanding of how behaviors can prevent
reproduced by overbreathing in the therapist's disconfirmation of feared disasters to devise
office, suggesting that the symptoms are both a direct tests; for example, a patient who felt weak
sign of anxiety induced by catastrophic mis- during attacks and believed that she was going
interpretations and also a result of stress- to fall would tense her muscles to prevent
induced hyperventilation, and (b) that strategies collapse. In the office therapy session, patient
which help them to control their thoughts and and therapist tried out how weak muscles would
breathing, although unnecessary for their safety, have to be to result in collapse. The patient
have the effect of reducing the symptoms, thus decided to test the possibility of falling at times
providing further confirmation of the noncatas- when she felt panicky and weak by trying to
trophic interpretation. (Note that, despite en- relax her muscles in the same way she had in the
couraging early clinical reports, breathing therapy session. This exercise had the effect of
control without the crucial cognitive element completely changing her belief in the possibility
has been shown to be ineffective; the cognitive of collapsing, integrating cognitive techniques
element appears to be necessary for successful with short behavioral experiments. These
treatment using respiratory control.) behavioral experiments, in which the patient
The therapist who wishes to deal effectively experiences a clear disconfirmation of the beliefs
with the problems of patients suffering from which had previously been the focus of safety-
panic attacks should also deal with those safety- seeking behavior, allow rapid and complete
seeking behaviors which the patient uses during modification of both avoidance behavior and
panic attacks. Typically, three main types of catastrophic interpretations.
behavior are seen: (a) avoidance of situations
which the patient believes might provoke panic
6.18.7.1.3 Effectiveness of cognitive-behavioral
(e.g., avoiding supermarkets); (b) escape from a
therapy
situation when a panic attack occurs (e.g.,
leaving a shop once the symptoms of panic Early clinical studies on both cognitive and
begin); and (c) safety-seeking behaviors carried behavioral treatments used consecutive single
out during panic with the intention of actively case series (see Salkovskis & Clark, 1986, and
preventing the feared catastrophe (e.g., when Barlow, 1988, for a review of these). These early
dizziness leads to the thought ªI'll faint,º studies used quasiexperimental designs which
holding on to another person, shopping trolley, required the measurement of a baseline,
or sitting down). Each of these behaviors can followed by the demonstration of change
Treatment 431
associated with treatment that was greater in unlikely to show spontaneous remission (i.e.,
magnitude than any variation seen during the those patients experiencing frequent panic
baseline period. Not only was it possible to show attacks with a minimum duration of six
this, but it was also shown in these relatively months); (ii) delivering each treatment in an
unselected samples that the changes associated optimum fashion, with considerable care being
with treatment (most patients being panic free at taken with treatment integrity (e.g., sessions
the end of treatment) persisted at two-year audiotaped and checked against the compe-
follow-up. These studies were criticized for not tency scale for cognitive therapy adapted for
being sufficiently selective about the patients panic treatment); (iii) ensuring that each
included and not adhering exactly to a preset treatment had an equally credible rationale
treatment protocol. For example, several of the and expectance of good outcome at the outset
patients in Clark, Salkovskis, and Chalkley's (i.e., before any differential effectiveness was
(1985) study required and were given additional apparent); (iv) the inclusion of as many
treatment for nonpanic related problems. As common elements as possible (e.g., daily
these people were treated as part of routine recording/self-monitoring, printed therapy
clinical practice, a certain (small) amount of time handouts early in treatment, self-exposure
was devoted to dealing with problems such as instructions in the later stages of treatment,
assertiveness difficulties, marital problems, and and so on); (v) use of blind assessor ratings as
so on. This was fully documented in the well as self-ratings; (vi) inclusion of high end-
published report, but was nevertheless a source state functioning criteria in outcome assess-
of some criticism, and highlighted the need to ment; (vii) maximum attention to follow-up
conduct better controlled studies. A later single completeness; and (viii) inclusion of theoreti-
case series (Salkovskis, Clark, & Hackmann, cally relevant variables to predict relapse.
1991) was used in a quite different way. In this The outcome of this study clearly indicated (i)
series, it was demonstrated that it was possible to that all three treatments were active (superior to
make a substantial impact on panic attack by waitlist); (ii) that both in the short term (12
using brief (two hour) and purely cognitive weeks) and long term (one-year post-treatment
(verbal) procedures. This study was consistent follow-up), cognitive therapy was significantly
with the hypothesis that cognitive change superior to both applied relaxation and imi-
(focusing on the modification of the misinter- pramine; (iii) that the degree to which cata-
pretation of bodily sensations) could be an strophic misinterpretations of bodily sensations
element in the effectiveness of cognitive therapy remained at the end of treatment predicted
for panic in reducing panic attack frequency. relapse at one-year follow-up, and that this
This study also gathered preliminary evidence remained the case when any residual sympto-
that cognitive procedures which do not target matology at the end of treatment was partialled
misinterpretations may not be effective. out; and (iv) that all treatments resulted in good
Following these clinically based studies which levels of high end-state functioning at the end of
demonstrated that the effectiveness of cognitive treatment and at one-year follow-up (CT 80%
therapy was unlikely to be due spontaneous and 70%; AR 25% and 32%; imipramine 40%
remission or to nonspecific factors (see also and 45%).
Beck, 1988), it was clearly important to assess The particular effectiveness of cognitive
the effectiveness of cognitive therapy compared therapy has been replicated in a number of
with the best available alternative psychological centers; a recent feature of this work has been
and pharmacological treatments. Clark et al. the coordination of outcome measures allowing
(1994) compared cognitive therapy to (i) a detailed comparisons across centers (Clark,
waiting list control group; (ii) imipramine 1994). Treatment outcome studies are also
delivered in the optimum fashion by an described particularly well in Clark (1994).
experienced biologically-oriented psychiatrist The next stages in this line of research is to (i)
(gradually increased to high doses maintained improve cost-effectiveness, that is, to evaluate
to six months then gradually tapered); (iii) whether it is possible to conduct treatment in a
applied relaxation, a specially modified form of smaller number of sessions without sacrificing
relaxation for use with panic (Ost, 1988); and the outstanding results found by our own and
(iv) cognitive therapy. All active treatments other groups, and, if a briefer treatment is found
were delivered by experienced therapists in the to be as effective. Work carried out by the
fashion currently considered optimum for each Oxford group on the treatment of panic
therapy; thus, psychological treatments were 12 disorder suggests that it is possible, by the use
sessions over 12 weeks, pharmacotherapy was of self-help manuals integrated with therapist
continued for much longer. contact, to reduce therapy time to around five
Important features of this study were (i) the sessions without loss of efficacy (Clark et al., in
selection of patients who were particularly preparation); (ii) to return to the initial strategy
of applying the therapy to a less selected clinical psychopathology correlates of the Fear Survey Schedule
sample of people suffering from panic attacks; (FSSIII) in a phobic population: a factorial definition of
agoraphobia. Behaviour Research and Therapy, 18,
(iii) to evaluate the generalizability of cognitive 229±242.
methods and theory developed in panic by Baker, R. (1989). Introduction: Where does ªPanic
adapting these to the needs of other patient Disorderº come from? In R. Baker (Ed.), Panic disorder:
groups such as hypochondriasis (Salkovskis, Theory research and therapy. Chichester, UK: Wiley
Ballenger, J. C. (1986). Pharmacotherapy of the panic
1989; Salkovskis & Clark, 1993; Salkovskis & disorders. The Journal of Clinical Psychiatry, 47(Suppl.),
Warwick, 1986; Warwick & Salkovskis, 1990). 27±32.
It is important to note that a range of other Ballenger, J. C., Burrows, G. D., DuPont, R. L., Lesser, I.
psychological treatments have been shown to be M., Noyes, R., Pecknold, J. C., Rifkin, A., & Swinson,
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and relaxation, termed Panic Control Treatment Psychiatry, 58(Suppl. 2), 32±37.
(Barlow, 1991; Barlow & Cerny, 1988). Barlow Barlow, D. H., & Cerny, J. (1988). Psychological treatment
(1997) suggests appropriately that some caution of panic. New York: Guilford Press.
Barlow, D. H., & Craske, M. G. (1988). The phenomen-
is needed before concluding that psychological ology of panic. In S. J. Rachman & J. Maser (Eds.),
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Barlow, D. H., Vermilyea, J., Blanchard, E. B., Vermilyea,
B. B., Di Nardo, P. A., & Cerny, J. A. (1985). The
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94, 320±328.
Both biological and psychological theories Bass, C., & Gardner, W. (1985). Emotional influences on
have generated a great deal of specific research breathing and breathlessness. Journal of Psychosomatic
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References 443
6.19
Worry and Generalized Anxiety
Disorder
THOMAS D. BORKOVEC and MICHELLE G. NEWMAN
Pennsylvania State University, University Park, PA, USA
6.19.1 NORMAL AND PATHOLOGICAL WORRY 439

6.19.2 DIAGNOSTIC DESCRIPTION OF GENERALIZED ANXIETY DISORDER 440
6.19.3 IMPORTANCE OF GAD 440
6.19.4 BASIC RESEARCH ON THE NATURE, FUNCTIONS, AND ORIGINS OF WORRY AND GAD 441
6.19.4.1 GAD and Information Processing 441
6.19.4.1.1 Worrisome thinking and emotional processing 441
6.19.4.1.2 Worrisome thinking and other information processing functions 442
6.19.4.2 The Psychophysiology of GAD 443
6.19.4.3 GAD and Interpersonal Factors 444
6.19.4.3.1 GAD and early childhood interpersonal factors 445
6.19.4.3.2 GAD and adult interpersonal factors 445
6.19.5 THERAPY OUTCOME INVESTIGATIONS OF GAD 445
6.19.5.1 Review of Past Controlled Therapy Outcome Studies of GAD 445
6.19.6 CLINICAL DESCRIPTION OF COGNITIVE-BEHAVIORAL THERAPY FOR GAD 447
6.19.6.1 Self-monitoring and Early Cue Detection 447
6.19.6.2 Stimulus Control Methods 448
6.19.6.3 Relaxation Methods 449
6.19.6.4 Applied Relaxation 451
6.19.6.5 Self-control Desensitization 452
6.19.6.6 Cognitive Therapy 453
6.19.7 SUMMARY AND IMPLICATIONS FOR FUTURE THERAPY DEVELOPMENT 456
6.19.1 NORMAL AND PATHOLOGICAL mental problem solving on an issue whose

WORRY outcome is uncertain but contains the possibi-
lity of one or more negative outcomes. Conse-
Research on worry began in the test anxiety quently, worry relates closely to fear processº
area in the 1970s, where the distinction was (Borkovec, Robinson, Pruzinsky, & DePree,
made between worry as a cognitive aspect of 1983a). So the early theoretical view of worry
anxiety and emotionality reflecting the physio- was that it was a cognitive avoidance response
logical features of anxious experience. An early to detected threat (Borkovec, Metzger, &
definition of worry suggested that it involved ªa Pruzinsky, 1986). Several studies indicated that
chain of thoughts and images, negatively affect worry was indeed functionally separate from
laden and relatively uncontrollable. The worry somatic anxiety and that it was primarily
process represents an attempt to engage in responsible for the interfering effects of anxiety
439
440 Worry and Generalized Anxiety Disorder
on test and grade performance (Deffenbacher, GAD focused on chronic, diffuse anxiety and its
1980). During the 1980s, experimental research symptoms of apprehensive expectation (worry),
devoted to exploration of the nature of the vigilance/scanning, motor tension, and auto-
worry process began. Inductions of worry were nomic hyperactivity. If other Axis I conditions
found to produce several important effects: were present, however, GAD was not to be
incubation of negative thought intrusions diagnosed. The arrival of DSM-III-Revised
(Borkovec et al., 1986; Pruzinsky & Borkovec, (American Psychiatric Association, 1987) was
1990; York, Borkovec, Vasey, & Stern, 1987), an important turning point. GAD was allowed
lengthening of decision-making times (Metzger, as a principal diagnosis even in the presence of
Miller, Cohen, Sofka, & Borkovec, 1990) due to most other disorders, and it was centrally
elevated evidence requirements (Tallis, Eysenck, defined as apprehensive expectation (worry).
& Mathews, 1991), absence of change in heart Its remaining symptoms were organized into an
rate (Borkovec et al., 1983a; York et al., 1987), 18-item checklist and designated as associated
elimination of the incubating effects of un- characteristics.
conditional stimulus rehearsal in the uncondi- Further revision occurred in DSM-IV (Amer-
tioned stimulus revaluation phenomenon ican Psychiatric Association, 1994) based on
(Davey & Matchett, 1994), and the generation comprehensive reviews of the extant empirical
of predominantly anxious but also depressive literature on GAD (Borkovec, Shadick, &
affect (Andrews & Borkovec, 1988). Remark- Hopkins, 1991). The disorder is now defined
ably, nonanxious groups displayed the very by excessive and uncontrollable worry about a
same effects during or after brief elicitation of number of events or activities not confined to
the worry process. Related research indicated other Axis I disorders, occurring more days than
that anxious thoughts were harder to dismiss not for at least six months, causing clinically
than neutral or depressing thoughts or intrusive significant distress or impaired functioning, and
negative images. Such research also showed that not due to the direct physiological effects of a
both the degree of worry about anxious substance or a general medical condition. The
thoughts and the presence of depressed states associated symptoms checklist was reduced in
could further decrease control over anxious size, based on empirical identification of the
thoughts (Clark, 1986; Clark & DeSilva, 1985; most frequent and reliable symptoms (Marten
Edwards & Dickerson, 1987a, 1987b; Suther- et al., 1993). Diagnosis requires the presence of
land, Newman, & Rachman, 1982). What only three of six symptom groups (restless/
generally emerged from this literature was that keyed-up/on-edge, fatigue, difficulty concen-
normal negative intrusive thoughts (including trating, irritability, muscle tension, and sleep
those of worry) were distinguishable from the disturbance). Interestingly, all six symptoms
pathological worry found in anxiety disorders reflect central nervous system (CNS) rather than
by neither their process nor effects but rather by autonomic nervous system (ANS) activity,
their frequency and intensity, which in turn matching what has been discovered in the
appeared to be due to their uncontrollability psychophysiology of GAD. Also of importance
(Clark, 1986; Clark & DeSilva, 1985; England & for the scientific generalizability and continuity
Dickerson, 1988; Kent & Jambunathan, 1989; of GAD research, clients who meet GAD
Parkinson & Rachman, 1981; Salkovskis & criteria by DSM-III-R routinely meet DSM-
Harrision, 1984). Despite growing interest in the IV criteria as well (Abel & Borkovec, 1995).
phenomenon of worry during this period, the
greatest boost to its investigation occurred when
worry became the central defining feature of 6.19.3 IMPORTANCE OF GAD
generalized anxiety disorder.
GAD may be a particularly important area of
experimental outcome and basic research. In
6.19.2 DIAGNOSTIC DESCRIPTION OF terms of psychopathology: (i) estimates in the
GENERALIZED ANXIETY 1990s (Kendler, Neale, Kessler, Health, &
DISORDER Eaves, 1992; Wittchen, Zhao, Kessler, & Eaton,
1994) suggest 3.6±5.1% lifetime and 3.1% one-
The diagnostic description of generalized year prevalence rates, and it is one of the most
anxiety disorder (GAD) has undergone several common comorbid conditions in the anxiety
changes in diagnostic definition. The label first and mood disorders (Brown & Barlow, 1992);
occurred in the third edition of the Diagnostic (ii) it may be the basic anxiety disorder (based
and statistical manual of mental disorders (DSM, on its early onset, chronicity, and resistance to
American Psychiatric Association, 1980); the change) out of which other anxiety disorders
older category of anxiety neurosis was divided often emerge (Brown, Barlow, & Liebowitz,
into panic disorder and GAD. The definition of 1994); (iii) worry, the central feature of GAD, is
Basic Research on the Nature, Functions, and Origins of Worry and GAD 441
pervasive in the anxiety and mood disorders maintenance, and how it is best treated. Results
(Barlow, 1988); (iv) worry has been experimen- suggest that the answers will likely be found in
tally demonstrated to prevent emotional pro- dysfunctional processes within and interactively
cessing and thus may maintain any disorder between three domains: information processing,
wherein such processing is important for thera- physiology, and interpersonal functioning.
peutic change (Borkovec, 1994); and (v) suc-
cessful treatment of GAD results in dramatic
reduction in comorbid conditions (Borkovec, 6.19.4.1 GAD and Information Processing
Abel, & Newman, 1995). So understanding the
mechanisms of GAD and developing effective Evidence indicates that GAD and its central
therapies based on that understanding may not worry feature are associated with impairments
only contribute to the amelioration of a very in several types of information processing, the
common disorder which is difficult to treat but most important of which is the processing of
may also have significant implications for the emotional material.
treatment and/or prevention of other disorders.
Investigation of GAD is also important in the
6.19.4.1.1 Worrisome thinking and emotional
more general pursuit of understanding human
processing
nature and its adaptive and maladaptive pro-
cesses. Research on GAD and worry has impli- When people worry, they are mostly talking
cated the mutually interactive influences of to themselves. Worry involves a prevalence of
several response systems (e.g., attention, inter- abstract, verbal-linguistic, thought as opposed
pretation of the environment, implicit and to imaginal process (Borkovec, 1994). This is
explicit memory, abstract thought, imagery, true for GAD clients and nonanxious controls
affect, central and peripheral physiology, and when they are worrying. During relaxation
behavior) in their processes and maintenance. states, GAD clients continue to experience the
Thus, the study of GAD may yield knowledge in predominance of thoughts, whereas nonanxious
general, about the nonlinear dynamical nature persons shift to a predominance of imagery.
of human functioning, viewed as a constantly Therapy for GAD clients leads to the normal-
changing process in response to a changing ization of thought and image frequencies
environment. Finally, recent basic research on (Borkovec & Inz, 1990). The extensive findings
GAD, especially on the role of developmental on the role of such cognitive factors and many
and interpersonal factors, holds considerable others in GAD (Mathews; 1990; Mathews &
promise for the development of more effective MacLeod, 1994) has long suggested the useful-
therapy. ness of cognitive therapy (CT) for the disorder.
The role of such cognitive factors is also fun-
damental to a specific theoretical view of the
6.19.4 BASIC RESEARCH ON THE nature and functions of worry. The distinction
NATURE, FUNCTIONS, AND between thought and imagery is crucial.
ORIGINS OF WORRY AND GAD Imagery is closely tied to efferent commands
into the affective, physiological, and behavioral
Clinical experience and empirical results systems; thought is not. Imagination of fear
suggest a straightforward description of the material elicits strong cardiovascular response;
inner life of GAD clients: it is necessary to verbally articulating the same material does not
search constantly for cues about possible future (Vrana, Cuthbert, & Lang, 1986). It is adaptive
threat (ªWhat if . . .?º) in order to avoid that thought evolved in this way. Its relative
catastrophes or to prepare ways to cope with isolation from efferent systems increases choice
their occurrence (Beck & Emery, 1985). Because and flexibility.
the dangers exist only in their minds and only in Worrisome thought, however, has the dis-
the future, behavioral avoidance is not an advantage that it precludes emotional proces-
available response. This leaves conceptual sing. Phobic persons who think worrisome
activity (i.e., worry) as one of the few coping thoughts just prior to repeated phobic image
resources. Human thought may well have presentations show no cardiovascular response
evolved specifically to anticipate the future, to at all to those images; those who think neutral or
avoid negative events, and to increase positive relaxing thoughts display significant response,
events (McGuire & McGuire, 1991). The central with relaxation producing habituation over
questions for GAD research, however, focus on repeated images (Borkovec & Hu, 1990;
why so much threat is perceived, what the Borkovec, Lyonfields, Wiser, & Diehl, 1993a).
specific nature, functions, and consequences of Moreover, worry after exposure to a stressful
the pathological worry response to threat might event also results in a failure to process the
be, what factors are involved in its origins and emotional material adaptively (Butler, Wells, &
Dewick, 1995; Wells & Papageorgiou, 1995). events involved death, illness, or injury related
From a neobehavioristic perspective, absence of to self or others (as required by DSM trauma
cardiovascular response to phobic information definition), this is the very category about which
reflects a failure to access the complete fear GAD clients worried the least. The avoidance of
structure stored in memory (especially its trauma content can in and of itself lead to the
efferent emotional meanings) and therefore an maintenance of anxious meanings, but a
absence of the kind of emotional processing traumatic experience may also provide actual
necessary for extinction (Foa & Kozak, 1986). evidence that the world (especially involving
One of the immediate functions of worry, then, other people) can indeed be a threatening place
is the avoidance of aversive images, somatic and further contribute to the origins and/or
anxiety, and other negative emotions, and the maintenance of GAD.
worrying is thereby strengthened via negative The implication of worry's function as cogni-
reinforcement. A significant consequence of this tive avoidance and its prevention of emotional
avoidance function is the maintenance of processing is far-reaching. Worry contains a
anxious meanings despite daily exposures to process that maintains GAD or indeed any
threat-related material and the potentially emotional disorder. Emotional change due to
corrective information that accompanies such daily life experiences or to deliberate exposures
exposures. These findings and their theoretical in therapy to emotional material is less likely to
context have long suggested the usefulness of take place to the degree that worry is present
imagery exposure (combined with relaxation) before, during, or after such exposures.
for accessing and changing emotional meaning The mechanisms for worry's inhibitory effect
in therapy for GAD. on emotional processing are unsubstantiated,
The above research supports the hypothesis but four possibilities have been suggested
that worry functions as a cognitive avoidance (Borkovec, 1994): (i) lessened attentional re-
response to threatening material. Analogue source for processing other information (Math-
GAD and control groups actually view worry ews, 1990); (ii) difficulty of shifting attention
in a similar way (Borkovec & Roemer, 1995). from excessive, habitual (especially negatively
When these groups rated possible reasons for valanced) thought activity (Parkinson & Rach-
worry, only one scale discriminated the two man, 1981); (iii) semantic satiation effects of
groups: ªWorrying about most of the things I repetitious worrisome thought, thus insulating
worry about is a way to distract myself from worry content from the rest of its associative
worrying about even more emotional things, network, especially affective associations
things that I don't want to think about.º (Smith, 1984); and (iv) less mismatch between
Although this could merely represent attempts information expected and received (a central
of the GAD participants to rationalize why they condition for anxiety in Gray's neuropsycho-
worry, it may also reflect a further avoidance logical theory of anxiety (Gray, 1982)). Future
function of worry: avoidance of more painful basic research might aim usefully at isolating the
emotional material. Rather than focus on specific mechanisms involved.
primary affect, the superficial content of worry
may be focused on secondary or instrumental
6.19.4.1.2 Worrisome thinking and other
affects.
information processing functions
What underlying content might be avoided is
speculative, but three candidates exist, and all Research evidence indicates that GAD and
relate to interpersonal issues. Two (negative worry are associated with various information
attachment experiences and current interperso- processing characteristics that interfere with
nal problems) are discussed later. The third learning from experience and thereby maintain
possibility resides in the fact that both GAD anxious meaning. GAD clients display (i)
clients and analogue GAD groups report more preattentive bias to threat cues, even outside
frequent past traumas than controls, and 65% of awareness and often with task-interfering
of these are interpersonal in nature (Roemer, effects, (ii) rapid cognitive avoidance of detected
Borkovec, Posa, & Lyonfields, 1991). Of course, threats such that explicit memory for the
when considering this evidence, we must be material is reduced but implicit memory is
mindful that recall is subject to distortion, the increased, and (iii) negative interpretations of
traumas could have occurred after the onset of and predictions from ambiguous and even
GAD, and many psychiatric groups report neutral information. Several of these effects
frequent trauma. However, content analyses of are accentuated for stimulus material directly
the trauma topics and worry topics reveal associated with the client's worrisome concerns
indirect evidence for avoidance of trauma (Mathews, 1990; Mathews & MacLeod, 1994).
memories (Shadick, Roemer, Hopkins, & Three further instances of worry effects on
Borkovec, 1991). Even though the traumatic information processing have emerged. First, in
Basic Research on the Nature, Functions, and Origins of Worry and GAD 443
the current therapy trial at the Pennsylvania do not produce differential activation compared
State GAD Project, clients monitor their daily to relaxed states (Borkovec et al., 1983b; Elliott,
worry predictions and rate actual outcomes once 1990). One study did find greater CNS-
they occur. In this study, the outcomes turned mediated muscle tension in GAD but no other
out better than expected 84% of the time, and in activation differences compared to controls
78% of the remaining situations, clients still (Hoehn-Saric, McLeod, & Zimmerli, 1989).
coped better than they predicted. Thus, in only However, GAD was characterized by reduced
3% of all worries did the core feared event (ªThe variability in autonomic measures, leading to
predicted bad event will occur, and I won't be the hypothesis that GAD involves sympathetic
able to cope with itº) actually happen. It is inhibition and an autonomic inflexibility rather
possible that GAD clients continue to worry than sympathetic activation (Hoehn-Saric &
despite consistent real world evidence that feared McLeod, 1988).
outcomes do not occur because they frequently Rigid autonomic functioning is implicated in
fail to process this corrective evidence. Second, several biological disorders (Thayer, Friedman,
people who worry about a topic prior to & Borkovec, 1996). Models of nonlinear
generating alternative predictions of what might dynamical systems view flexible responding as
happen generate exclusively negative predic- a marker of system integrity, and these models
tions, whereas people who relax before generat- interpret reduced variability to be pathological
ing the alternatives list only positive predictions (Goldberger, 1992). The hypothesis that GAD is
(Borkovec, 1995). This suggests that worrying characterized by a distinctive physiology invol-
increases cognitive rigidity and that this rigidity ving restricted range of variability thus takes on
precludes the retrieval of realistic corrective added importance. However, the speculation
information. Third, several studies have demon- that this is due to sympathetic inhibition may be
strated poor recall (reflecting cognitive avoid- an oversimplification of complex autonomic
ance) of threat words in GAD (cf. Mathews, activity which involves both sympathetic and
1990). However, a study by Thayer and parasympathetic branches.
Borkovec (1995) attempted to replicate these Evidence supports the specific importance of
findings using a higher-order classical condi- chronic parasympathetic (vagal) deficiency in
tioning task (i.e., emotional words as the GAD. Analogue GAD participants display
unconditional stimuli). In this study, GAD tonically lowered vagal tone and little variation
clients were exposed to 10 threat words in either vagal tone or heart rate during rest,
(preceded by a colored block, the conditional aversive imagery, and worrisome thinking
stimulus) and 10 nonthreat words (preceded by a (Lyonfields, Borkovec, & Thayer, 1995). Non-
differently colored block) in random order. anxious participants show decreases in vagal
Clients merely read the words silently as they tone from rest to emotional tasks and the
appeared, but they were given a surprise recall greatest reduction during worry. Thus, GAD is
task at the end. Contrary to results of prior characterized by autonomic inflexibility, such
research, clients recalled more threat than rigidity is due to a chronic deficiency in
nonthreat words and to a greater degree than parasympathetic tone, and worrisome thinking
nonanxious participants. Whereas previous can cause such reductions. Replicated findings
research was based on brief exposures and/or emerged from a comparison of GAD clients to
instructions to actively respond to the words, nonanxious participants during periods of self-
Thayer and Borkovec used a longer exposure relaxation and worry (Thayer et al., 1996).
time. This suggests that lengthier exposures GAD was characterized by a tonic deficiency in
during a passive task will enhance threat recall vagal tone, and a main effect of tasks indicated
from explicit memory, perhaps by overriding the that worry phasically caused that deficiency in
defensive process of cognitive avoidance. GAD and nonanxious participants. These
Taken as a whole, the above research indi- results make dramatic sense if we combine
cates that GAD is characterized by habitual, what is known empirically about GAD (e.g.,
inflexible cognitive and affective processes. A chronic vigilance to threat, frequent aversive
parallel rigidity has also been found in the tonic cognitions with a predominance of worrisome
physiology of GAD and the phasic physiology thought, excessive muscle tension, and difficulty
of worry. concentrating) with results from experimental
physiology: tasks that phasically cause reduced
vagal tone among normals include threat of
6.19.4.2 The Psychophysiology of GAD shock, recall of past aversive events, mental
problem-solving, and isometric hand-grip
Unlike the results from other anxiety dis- (Grossman, Stemmler, & Meinhardt, 1990;
orders, physiological activation is not always Grossman & Svebak, 1987). Moreover, vagal
characteristic of GAD, and inductions of worry deficiency provides a physiological basis for the
habitual, GAD-characteristic attentional pro- The latter result indicates that classically
cesses mentioned previously, given that poor conditioned orienting responses (indicating
attentional concentration and distractibility are increased attention) emerge in GAD over
related to lower vagal tone in both infants repeated exposures to verbal threat material,
(Richards, 1987) and adults (Porges, 1992). The and provides a basis both for GAD hypervigi-
above research demonstrating vagal deficiency lence and for the generalization of threatening
and autonomic inflexibility in GAD reinforces meaning via associative learning processes
the long-held view of the usefulness of relaxa- which depend solely on words as the uncondi-
tion methods in the treatment of GAD. These tional stimulus. These results may have sig-
results also provide a clear physiological basis nificant implications for understanding the
for the finding that CNS but not ANS symp- interrelationships between the processing of
toms characterize the self-reports of GAD verbal material, attention, associative emo-
clients (Marten et al., 1993). tional learning, and physiology in GAD.
This GAD-distinctive inflexibility also makes Thus far, we have reviewed information on
sense when considering the psychological situa- the intrapsychic patterns of GAD showing
tion that GAD clients face. Their threats are inflexible and repetitious cognition, affect, and
illusory, exist only in their minds, refer to a physiology. Several lines of research have also
nonexistent future, and are based on fears of explored the possibility of habitual patterns in
events having a low probability of occurrence. overt behavior, particularly those in the domain
The clients thus face an insoluble problem of interpersonal functioning. Such research has
wherein fight-or-flight activation is inhibited found evidence for recurrent, problematic,
because there is no one to fight and nowhere to interpersonal behavior as well as for possible
flee, analogous to the freezing response of rats connections between adult interpersonal styles
when motoric avoidance to feared stimuli is and early attachment experiences.
prevented.
Electroencephalogram (EEG) differences
have also been discovered between nonanxious 6.19.4.3 GAD and Interpersonal Factors
groups and both GAD clients and chronic
worriers (e.g., greater frontal beta and less For many years, researchers have known of a
parietal alpha for the latter) as well as between significant connection between GAD and inter-
relaxation and induced worry tasks (e.g., greater personal factors. Several lines of evidence have
frontal and parietal beta during worry) (Carter, contributed to this knowledge. First, patterns of
Johnson, & Borkovec, 1986; Inz, 1990). Im- familial history in GAD (Noyes, Clarkson,
portantly, inflexibility was also revealed in the Crowe, Yates, & McChesney, 1987; Noyes
cortical activity of GAD clients; lowered et al., 1992) along with a low degree of
variability was found in alpha and beta over heritability (Kendler et al., 1992; Torgersen,
several laboratory tasks (Inz, 1990). 1986) imply that interpersonal developmental
Although restricted, tonic cardiovascular experiences may provide some etiologic founda-
functioning appears to be characteristic of tion for GAD. Second, although GAD clients
GAD, a close look at phasic heart rate reactions worry about many topics, they are particularly
to threatening material reveals that brief initial afraid of interpersonal situations: social phobia
activation can occur. Results from the threat/ is the most frequent comorbid diagnosis for
nonthreat word conditioning task described GAD (Barlow, 1988; Borkovec et al., 1995);
earlier have shown that: (i) nonanxious parti- trait-worry correlates more highly with social
cipants showed larger orienting responses to fears than with nonsocial fears (Borkovec et al.,
threat and nonthreat words than GAD clients; 1983b); content analysis of GAD worry topics
(ii) their magnitude was related to resting vagal reveals interpersonal concerns to be more
tone (described earlier to be deficient in GAD frequent than any other domain (Shadick et al.,
and intimately related to attentional mechan- 1991). Finally, worry involves a predominance
isms); (iii) the control group, but not GAD of thought; thought is based upon language;
group, showed habituation of physiological language is based on social communication.
response over both threat and nonthreat trials; Thus, some features of thought (talking to
(iv) GAD clients, but not the control partici- ourselves) are inherently interpersonal (Borko-
pants, displayed heart rate acceleration (the vec et al., 1991). Together, these observations
classic ªdefensive responseº) to threat words; suggest that a history of negative interpersonal
and (v) the GAD group, but not the control experiences may contribute to the origins or
group, developed an anticipatory heart rate maintenance of GAD, to current interpersonal
deceleration to the colored block preceding functioning, to the maintenance of an excessive
threat words but not to the block preceding perception of threat, and/or to learned worri-
nonthreat words (Thayer & Borkovec, 1995). some thought styles to cope with threat.
Therapy Outcome Investigations of GAD 445
6.19.4.3.1 GAD and early childhood interpersonal distress (not surprisingly) but also
interpersonal factors a greater rigidity in their interpersonal styles
across differing situations than nonanxious
Bowlby (1982) was quite specific about
people (Pincus & Borkovec, 1994). Thus,
hypothesized relationships between attachment
GAD has now been shown to reflect inflexibility
and anxiety. If a child has a primary attachment
in cognitive, affective, central physiological,
figure who is repeatedly unavailable, the
peripheral physiological, and interpersonal
resulting insecure base may manifest itself in
behavioral domains. More importantly, cluster
the child's developing mental models of the
analysis has revealed three subtypes of GAD,
world as a dangerous, frightening place, with an
replicated in both initial and cross-validation
overestimation of the probability and severity of
samples. The first of the two smaller clusters
feared events and an underestimation of coping
(24.3% of the clients) involved social avoidance
resources. These mental representations are
and nonassertiveness, whereas the second
strikingly similar to those present in adult
cluster (13.5%) was characterized by elevated
GAD. Indeed, diffuse anxiety was felt by
domineering and vindictive scales. The primary
Bowlby to be the typical consequence of some
interpersonal problems for GAD (62.1% of the
forms of insecure attachment.
clients) were found on the overly nurturant and
The Inventory of Adult Attachment (IAA,
intrusive scales. Relating this to the attachment
Lichtenstein & Cassidy, 1991) is based on Main
results, the majority of GAD clients may have
and Goldwyn's (in press) system for scoring
learned in childhood to care for others in order
their Adult Attachment Interview (George,
to get love, approval, and nurturance, and they
Kaplan, & Main, 1985) and on Bowlby's
may continue to repeat this pattern in adult-
attachment theory. Results using the IAA
hood for the same reason. Worry may thus
indicate that the GAD groups score higher
function, as it did in childhood, as a means of
than nonanxious groups on role-reversed/
anticipating the needs of, and threats to,
enmeshed relationships but not on childhood
significant others in the pursuit of satisfying
rejection (Borkovec, 1995). The child had to
interpersonal needs. The discovery of this
take care of the parent rather than the parent
majority cluster, along with the attachment
taking care of the child. This suggests an
results, also fits well with research (Peasley,
understandable basis for the adult GAD view
Molina, & Borkovec, 1994) showing that GAD
of the world as a potentially dangerous place, of
groups report higher degrees of empathy on the
oneself as unable to cope, and of the need to
Interpersonal Reactivity Index (Davis, 1980).
constantly anticipate threats as the necessary
This empathy was most prevalent in the realm of
means to obtain love, approval, and nurturance.
feeling other people's pain. Thus, attempts by
The clients also reported greater unresolved
GAD clients in the overly nurturant cluster to
feelings of anger and vulnerability toward their
take care of others may also be motivated by
primary caregiver. Both the enmeshment and
attempts to reduce one's own pain caused by
anger/vulnerable findings are discussed more
intensely feeling the pain of others.
fully below in relation to findings on adult
interpersonal styles. Finally, the GAD group
reported greater difficulty remembering their 6.19.5 THERAPY OUTCOME
childhood. Whether the latter reflects motivated INVESTIGATIONS OF GAD
cognitive avoidance of negative memories or the
fact that GAD clients have a harder time Although the findings on the possible role of
remembering anything due to the sheer amount interpersonal factors in GAD suggest that such
of conceptual activity in which they are factors may become a very important feature in
constantly engaging is not yet known. the future development of more effective
therapies, all controlled therapy outcome
investigations to date have involved evaluations
6.19.4.3.2 GAD and adult interpersonal factors of behavioral and cognitive-behavioral therapy
(CBT) treatments that target intrapersonal
Clinicians often discover that many of the
anxiety process.
concerns raised by their GAD clients relate to
interpersonal relationships. Research at the
Pennsylvania State Project (Pincus & Borkovec, 6.19.5.1 Review of Past Controlled Therapy
1994) has made use of the Inventory of Outcome Studies of GAD
Interpersonal Problems Circumplex Scales
(IIP-C, Alden, Wiggins, & Pincus, 1990) to Systematic development and evaluation of
assess the interpersonal functioning of GAD psychotherapies for GAD began only recently
clients in a psychometrically sound way. Results for two reasons. First, GAD has historically
indicate that GAD clients show not only greater been an ambiguous disorder with frequent
changes in diagnostic definition. Second, the Turvey, 1987; Lindsay, Gamsu, McLaughlin,
etiology of GAD was not well explained by the Hood, & Espie, 1987). Finally, a twelfth GAD
discrete conditioning events that have been used study found CBT to be superior to anxiety
to elucidate the origins of other anxiety management at six-month follow-up and super-
disorders. Moreover, because conditioned en- ior to brief psychodynamic therapy at post-
vironmental triggers for anxiety were not therapy and follow-up (Durham et al., 1994).
obvious, and internal cues were more function- However, several methodological flaws render
ally relevant, the utility of exposure methods the conclusions questionable (brief duration of
was less clear for the diffuse forms of anxiety GAD, therapist-by-treatment confound, lower
found in GAD. Thus, early treatments for GAD credibility for the psychodynamic condition, no
emphasized the somatic aspects of the client's therapy manuals, large drop-out rate, higher
anxiety and trained clients to use relaxation severity for the psychodynamic condition, and
techniques as a general coping response when- no therapy integrity checks).
ever they felt anxious. Later developments Despite these promising effects, three areas of
involved the addition of elements from beha- concern exist (Borkovec & Whisman, 1996).
vioral self-control and cognitive treatments. First, the role of nonspecific factors or individual
These elements included an emphasis on CBT components remained unclear until the late
thorough applied relaxation training (OÈst, 1990s. Although placebo and individual ele-
1987), rehearsal of relaxation and cognitive ments have yielded less change than CBT,
coping responses during imaginal exposures to between-group effects have not always emerged.
environmental and internal fear cues (e.g., self- Second, clinically significant change for CBT
control desensitization (Goldfried, 1971), anxi- has been moderate at best (50% high endstate
ety management training (Suinn & Richardson, functioning on average across studies). An
1971), and CT aimed at modifying the GAD earlier review of nine of these studies came to
client's constant perception of threat (Beck & similar conclusions (Chambless & Gillis, 1993).
Emery, 1985). The emerging view of GAD, Finally, although their methodology has been
based on growing evidence concerning its nature fairly good (e.g., frequent use of manuals,
and the specific functions of worry, now sees it diagnostic interviews, integrity checks, and
as a loosely structured cognitive-affective state expectancy/credibility assessments), significant
(Barlow, 1988) whose process is characterized deficiencies exist in the majority of the studies.
by spiraling, habitual, inflexible interactions of Most importantly, only three studies required
multiple systems responding to constantly two independent diagnostic interviews. Princi-
perceived threat (Borkovec & Inz, 1990). Thus, pal GAD has the lowest interassessor kappa
intrapersonally focused CBT was designed to among anxiety disorders (Barlow & DiNardo,
provide multiple coping responses for the 1991). Absence of independent diagnosis raises
targeting of each of the maladaptive reactions the possibility of false-positive cases (as many as
and their interactions and to replace anxiety- 25±30%). Increased error variance due to false-
maintaining spirals among these systems with positive cases may explain why CBT has not
alternative responses. Such a treatment should always produced significantly greater improve-
be able to help an individual to develop a ment than nonspecific or component conditions
flexible, adaptive lifestyle conducive to reduced and why prior basic research on GAD has often
anxious experience. yielded ambiguous or conflicting results.
Only 12 controlled outcome studies on DSM- Somewhat greater clarity on the issue of
defined GAD have been published. Review of nonspecific effects and the contribution of
11 of these studies indicated that indeed CBT individual CBT elements was achieved in a
produces both statistically and clinically sig- comparison of applied relaxation, CBT (applied
nificant change, with maintained or increased relaxation, self-control desensitization, and
improvement up to a year later (Borkovec & brief CT), and a reflective listening control
Whisman, 1996). This therapy has also been condition (Borkovec & Costello, 1993). Unlike
associated with low drop-out rates, declining many prior studies, this study required two
use of psychotropic medication, and the largest independent diagnostic interviews, as well as
degrees of change among contrasted therapies quality and adherence checks of the therapy
and control conditions on both anxiety and provided. At post-therapy, applied relaxation
depression measures. Fifteen earlier outcome and CBT were superior to reflective listening,
studies of ªgeneral anxietyº are consistent with despite the fact that reflective listening was
the GAD trials: anxiety management has superior to the other two conditions on depth of
produced long-lasting gains that were some- emotional processing as objectively measured by
times superior to component conditions, and the Experiencing Scale (Klein, Mathieu-Cough-
CT techniques may add to post-therapy and lan, & Kiesler, 1986). However, at 12-month
especially follow-up improvement (Durham & follow-up, clients in the reflective listening
Clinical Description of Cognitive-behavioral Therapy for GAD 447
condition had lost most of their gains and had therapeutic targeting of interpersonal problems
more frequent subsequent therapy, clients in (Borkovec, 1995). Three of the IIP-C scales that
applied relaxation had maintained their gains, significantly contributed to the clustering
and those in the CBT condition showed further results (domineering, overly nurturant, and
gains and had higher endstate functioning (50% intrusive) failed to change significantly after
of the clients) compared to the other two CBT. Most importantly, these three scales (plus
conditions. These findings support the view that the vindictive scale) negatively predicted out-
a cognitive behavioral treatment for a multi- come, and these relationships were stronger at
dimensional disorder like GAD will be most follow-up than at post-test. Thus, interpersonal
effective if it targets each (cognitive, physiolo- problems, if left unattended in therapy, may be
gical, and imaginal) system found in basic especially associated with failure to maintain
research to play a significant role in GAD. therapeutic gains obtained by intrapersonally
The fact that reflective listening produced oriented CBT.
greater levels of emotional processing but failed
to achieve a better outcome in the above trial
suggests that the type of emotional processing 6.19.6 CLINICAL DESCRIPTION OF
that occurred was not therapeutically relevant COGNITIVE-BEHAVIORAL
to this disorder. From an experiential perspec- THERAPY FOR GAD
tive, the primary affects most centrally involved
Despite limitations in CBT, both in degree of
in emotional disturbance are not easily accessed
improvement and failure to address potentially
in GAD when reflective listening alone is
important interpersonal issues, it is the only
provided; the avoidant function of worry may
therapy method for GAD which has been
yield a client focus on secondary or instrumental
empirically validated (Chambless et al., 1996).
affect (Greenberg & Safran, 1987). For emo-
This section will provide a clinical description of
tional processing to occur, more potent techni-
the CBT elements which are most frequently
ques for accessing and deeply experiencing
used in controlled trials with the disorder. The
underlying, primary emotions in the present
protocol treatments in these trials have de-
moment may be necessary. But the development
pended on such basic resources as Beck and
of such a therapeutic focus, either for exposure
Emery's (1985) text on CT with anxiety
treatment or for experiential techniques, must
disorders and Bernstein and Borkovec's
await future research which identifies what
(1973) manual on progressive relaxation train-
those primary fears might be in GAD.
ing. The principles and techniques of those
The current therapy study in the Pennysyl-
approaches will not be reviewed here in detail.
vania State Project compares applied relaxa-
Instead, the present section will describe clinical
tion/self-control desensitization, CT, and their
adaptations of basic behavioral and cognitive
combination. Therapy time was increased by
therapy methods specifically for GAD, adapta-
50% to allow for more complete CT than in the
tions which have often been guided by the basic
previous trial. Preliminary results based on a
empirical research on the disorder summarized
partial sample have indicated that one-third of
earlier in this chapter.
the clients in each of the three conditions
reached high endstate functioning by the end of
therapy. At both follow-ups, however, the 6.19.6.1 Self-monitoring and Early Cue
combined CBT group had increased to a 50% Detection
rate, whereas the two single-element conditions
lost endstate gains. Should these outcomes hold Self-monitoring of anxiety cues on a moment-
up once all clients have completed therapy, they to-moment basis is foundational to CBT with
will support the already existing trend in the GAD. Although the identification of environ-
outcome literature suggesting that long-term mental cues is important, greater emphasis is
maintenance is indeed best produced by a placed on determining relevant internal cues
combined CBT therapy that targets each of the that trigger anxiety and worry. The latter
intrapersonal anxiety response systems. How- include attention, thoughts, images, bodily
ever, it is also clear that the attempt to increase sensations (especially muscle tension), emo-
the efficacy of CBT by doubling therapy time tions, and behaviors. Human experience is
was not successful. CBT outcome at follow-up described to the client as an active process
was not significantly different from previous involving the interaction of these internal cues
trials. This strongly suggests the wisdom of as they respond to a constantly changing
looking elsewhere to develop more powerful environment. Anxiety is the result of an
therapeutic approaches for GAD. Further incremental process that develops as each
preliminary results from this ongoing trial internal cue is triggered by other cues in a
strongly suggest that this may well involve the combined effort to respond to perceived threat.
For example, a person has a thought, which client's environment (e.g., checking every half-
triggers an emotion, and that emotion triggers hour, at every change in activity, and in response
another thought which triggers muscle tension, to noticing post-it notes placed in noticeable
which leads to the spiraling up of anxiety. It is locations). Over time, increasingly specific
not our reactions to events that are the problem; reminder cues which are particularly suited to
the initial reaction is quite natural and under- the anxiety process of individual clients can be
standable, given our past history of learning. identified and used (e.g., whenever the phone
The problem resides in our reactions to our rings, whenever a particular co-worker or family
reactions. These are the habits which we have member is first seen during the day, whenever
developed and that are further strengthened the client notices foot-tapping or hair-twisting
each time we allow their entire sequence to behaviors). The important thing is that a
occur. In therapy, the deliberate changing of sufficient number of effective cues are estab-
reactions to our reactions and the strengthening lished to frequently remind clients to observe
of new coping responses in each relevant system their inner processes. The ultimate goals are to
are targeted. Emphasis is therefore placed on establish a habit of recognizing incipient anxiety
increasingly early detection of internal changes and to intervene at that moment with whatever
occurring in an anxious direction. The earlier we coping responses have been learned up to that
can identify incipient cues for anxiety, the earlier point.
we can intervene. Any new intervention will be Self-monitoring need not be focused only on
more effective in reducing anxiety if it is applied anxiety cues. Both worry in general and GAD in
earlier in the spiral. particular are associated with other important
Asking clients to describe typical anxiety emotional experiences (e.g., anger, frustration,
experiences in terms of what they attend to, do, depression) as well. Learning to detect the
think, imagine, and somatically and emotion- incipient cues for each of these emotional
ally feel is a good starting point. However, the experiences and to distinguish them from
use of imagery of past or upcoming anxiety- anxiety will facilitate the application and
provoking situations can help clients more mastery of interventions better suited to them
accurately identify the internal contents and and/or may lead to the identification of their
sequences of actual anxious experience. The use functional role as the beginning point or
of a repeated image can help clients attend to consequence of an anxiety spiral.
each relevant system and to practice the early
detection of relevant cues. This in-session 6.19.6.2 Stimulus Control Methods
exercise also provides a concrete rehearsal of
the very self-monitoring that clients are asked to Because it occurs in numerous situations, the
practice in daily life. Of particular importance is worry process is usually under poor discrimi-
the actual worry process. Asking clients to native control. However, once clients have
worry silently about a typical topic of concern learned to detect the occurrence of worry, the
allows them to observe and describe this process therapist can introduce a very simple stimulus
in a more objective way. Asking them to control method for reducing the amount of time
subsequently worry out loud is often useful as spent worrying. A degree of stimulus control
well. This exercise gives the therapist some hints can be re-established by providing clients with
about what the nature and content of worry are five instructions.
for a specific client. (i) Establish a 30-minute worry period to
The therapist also observes clients for any occur at the same time each day and in the same
detectable shift in their affective state and place (a place not associated with other daily
immediately asks them to describe what is activities).
occurring. In this way, the therapist serves the (ii) Learn to detect the worrying at earlier
role of early detector of incipient anxious spirals and earlier moments, with the goal to ultimately
and facilitates client recognition of early cues. identify its onset.
Clients are encouraged to tell the therapist when (iii) As soon as it is detected, postpone it to
they notice the beginning of anxiety cues. Such your worry period. Remember that you will
encouragement allows the therapist to fade out have plenty of time to focus on your worry at
prompting as clients rehearse their own early that time and there is no need to make yourself
detection, the very goal of self-monitoring in miserable by worrying now when you have
daily life. better things to do. Also keep in mind that
Clients are encouraged to practice self- short-circuiting worry will help reduce its habit
monitoring on a daily basis between sessions. strength.
Remembering to do so is the most difficult (iv) After postponing the worry, focus your
challenge, so the therapist provides a variety of attention on the present environment or the task
suggestions for establishing reminders in the at hand.
(v) Use your worry period to worry intensely breathe in evenly and then again as you evenly
or (later in therapy) to employ some of the CT exhale.º A few minutes of diaphragmatic
strategies to eliminate the source of the worry- breathing practice helps clients learn what
ing. relaxation feels like and how to elicit it quickly.
Although empirical support for the efficacy They are encouraged to shift to this type of
of this technique is available on college samples breathing whenever they notice thoracic breath-
of chronic worriers (Borkovec, Wilkinson, ing in order to develop diaphragm breathing as
Folensbee, & Lerman, 1983c), a full clinical a habit. This coping response can also be used
trial to evaluate its usefulness in GAD samples upon early cue detection during daily self-
has not yet been conducted. Clinical experience monitoring as an initial method for learning to
suggests, however, that this simple method can control anxiety spirals. Moreover, when the
often provide some beginning relief fairly therapist cues the client to become aware of
quickly. increased anxiety during the session, the
therapist can ask them to apply this relaxation
6.19.6.3 Relaxation Methods response for a brief moment to reduce those
cues, thus giving clients immediate opportu-
Because autonomic inflexibility is character- nities for rehearsing applied relaxation.
istic of GAD physiological process, training in Training in progressive muscle relaxation
multiple relaxation methods for flexible appli- (PMR) involves systematically tensing and
cation as well as to strengthen parasympathetic releasing various muscle groups throughout
tone is desirable. Such relaxation methods can the body. This exercise causes a lengthening of
include paced diaphragmatic breathing, pro- muscle fibers which results directly in reduced
gressive muscle relaxation, guided imagery, muscular tension and indirectly in reduced
meditation, and, most importantly, daily ap- sympathetic activity. Clients formally practice
plication of applied relaxation. Clients are the technique twice a day to deepen their
encouraged to experiment with the different relaxation response and to strengthen their
techniques in response to different response ability to generate it in daily applications. As
system reactions and to identity which ones are therapy progresses, muscle groups are com-
most helpful under which circumstances. With bined, and tension production is eventually
several coping responses available, the like- replaced by relaxation-by-recall, wherein clients
lihood of finding an effective one in any given merely identify extant muscle tension and let go
situation increases, and clients develop an of that tension by recalling how those muscles
increased sense of choice and flexibility as well. felt when tension was produced and released.
When new cognitive or behavioral techniques The notion of ªletting goº of muscular
are introduced in therapy, it is helpful to do tension is inherent in PMR. Each time clients
demonstrations wherein the clients' own de- let go of tension in a particular muscle group,
ployment of strategies produces an immediate, they become a little more relaxed. Once clients
noticeable, and positive effect, however slight. are accustomed to producing relaxation by
In this way, clients obtain a sense that the concretely releasing muscular tension, the
technique can make a difference for them with therapist can introduce the analogous notion
further practice and application. Slowed, paced, of letting go of other processes involved in their
diaphragmatic breathing produces a rapid anxiety spirals. For example, clients can also
relaxation response with little training and practice the gentle letting-go of distressing
can be immediately used in daily living. The thoughts, worries, images, bodily sensations,
therapist models and has clients imitate both and negative emotional experiences. They can
rapid, shallow, thoracic breathing (a sympa- be reminded that it is their reactions to their
thetic elicitor) and slowed diaphragm breathing reactions that make a difference.
(a parasympathetic elicitor). In this way, clients Meditational techniques are often useful
learn that the way that they breathe affects how because they specifically emphasize attention
they feel and that they can exert some immediate to a single focusing device. Strengthening one's
control on physiological and psychological ability to shift attention away from anxiety-
states merely by controlling respiration. Typical provoking cognitions to one pleasant, internal
instructions for diaphragmatic breathing would stimulus is particularly helpful for GAD clients
be: ªShift to breathing from your stomach whose mental life is often consumed with
rather than from your chest. Allow your attention to worrisome thoughts and cata-
diaphragm to rise and fall without expanding strophic images. The therapist can ask clients
your chest. Also, slow your breathing down to a to use diaphragmatic breathing for this purpose,
rate slower than usual but not so slow that it is or they can work with the client to identify a
unpleasant or uncomfortable. You might do specific image or word which taps into previous
this by counting from one to three as you senses of safety, comfort, security, love, and/or
tranquillity. The word, ªhome,º for example, for venting this problem. Stressing the notion of
some clients may be associated with special, movement toward relaxation is one. Another is
positive meaning. For other clients, inter- to teach an alternate relaxation technique;
personal connections (e.g., an image of one's clients who experience RIA with one type of
infant daughter) might serve this purpose. relaxation tend not experience it with another
Clients are asked to practice meditational (Heide & Borkovec, 1983). Moreover, when the
methods by focusing on the pleasant internal emphasis is on frequent applications of brief
stimulus for a few moments at the end of formal relaxation responses to detected anxiety cues
PMR practice and to incorporate the use of rather than on twice-a-day formal practice of
this technique into their daily relaxation deep relaxation, there is less likelihood that
applications. clients will experience RIA. Finally, treatment
Guided imagery can also be introduced by of RIA in more difficult cases is analogous to
selecting scenes which are associated with exposure treatment of any feared event: training
tranquillity and pleasantness. Scenes can be can be systematically conducted in a graduated
constructed such that they sequentially produce fashion, with exposures to increasingly deeper
deeper states of relaxation and varying types of levels of relaxation over sessions. In our current
additional positive affect. Although guided therapy trial using these methods, the correla-
imagery is not useful for the rapid elicitation tion between in-session RIA and therapeutic
of a relaxation response during early cue improvement is no longer significant.
detection, it is a helpful device for deepening One of the overarching goals of relaxation
relaxation during formal practice sessions or at training and application with GAD clients is to
other moments in the day when a relaxation increase the amount of time spent focusing on
break is taken in order to reduce built-up the present moment rather than on anxiety-
anxiety and tension. provoking thoughts and images about the
Many GAD clients are perfectionistic, with future or the past. Early sessions devoted to
high performance standards for themselves and the identification of internal triggers to the
fear of the judgments of others. Consequently, anxiety spiral have already demonstrated to
attempting to achieve a completely relaxed state clients that what they are thinking and imagin-
may, in itself, generate anxiety which may ing contributes significantly to their anxiety;
interfere with that very goal. The therapist can they are partly creating their realities. The next
describe relaxation training in terms of ªmove- step is to discuss the fact that, when we are
ment toward relaxation.º Applied relaxation is thinking about the future or the past, we are
merely a matter of shifting the direction of the creating an illusion. These future and past
internal process away from a spiral of tension events do not exist now. But we still react
and anxiety; the movement toward relaxation emotionally as if they are actually occurring.
process, no matter how slight, is one of the most Images are particularly powerful elicitors of this
useful directions because of its direct incompat- effect; they can cause nearly the same degree of
ibility with anxiety. Frequency of application is physiological reactivity which the occurrence of
more important than depth of relaxation. Other the real events they reflect would cause. So we
than movement toward relaxation, there is no produce much of our anxious experience merely
end-state being sought either during training by thinking worrisome thoughts and imagining
and practice or in application. catastrophic scenes. A second disadvantage
Perfectionism is only one example of a basis exists when clients pay excessive attention to
for relaxation-induced anxiety (RIA), a phe- the future or the past. As long as they are not
nomenon common among diffusely anxious paying attention to the immediate environment,
individuals. Other possible reasons include the they are not processing further information
potentially frightening nature of unfamiliar from the actual world; there can be little
cognitive or physiological activity elicited by learning and development in their knowledge
relaxation, fear of losing control, and increased and adaptive behavior. The therapeutic im-
awareness of feelings of anxiety or other plications of this are clear: the more time clients
emotions (Heide & Borkovec, 1984). If the very spend focused on what is real and in front of
method for reducing anxiety is itself anxiety- them, the less time they spend creating negative
provoking, the likelihood of a therapeutic effect emotional experience and the more time they
in its application is minimal. Indeed, in the three spend processing adaptive information. Conse-
published GAD therapy investigations which quently, the therapist works with clients during
measured the occurrence of RIA during train- sessions to practice focusing attention on what is
ing, the degree of its occurrence negatively actually present. Initially, with eyes closed,
predicted outcome (Borkovec & Costello, 1993; clients are asked merely to attend to sounds
Borkovec & Mathews, 1988; Borkovec et al., occurring in the environment, the tactile feelings
1987). Fortunately, methods exist for circum- of the chair, and the odors in the air. They are
instructed to return their attention to these are detected. Although clinical applications of
sensations whenever they notice their attention relaxation had certainly been grounded more
drifting to other thoughts or images and to sense thoroughly in the importance of daily applica-
them without making judgments or elaborating tions, it was not until OÈst's article on applied
on their further meaning or associations (i.e., no relaxation (AR) that clinically thorough relaxa-
reactions to reactions). The same exercise is then tion training was incorporated into therapy
repeated with eyes open, and later as they walk research (OÈst, 1987). Evidence has now accrued
around the office. They are finally encouraged to indicate that this technique by itself can be a
to increasingly practice shifting to this kind of potent coping strategy for several anxiety
focus throughout the day and to let the therapist disorders.
know in the next session what new sensations The essential feature of AR is the frequent
they have discovered across multiple situations. elicitation of relaxation in response to anxiety
As clients report that relaxation applications and tension triggers. With GAD clients, this
are beginning to have some noticeable effects, would include worrying. The therapist has
they are further encouraged to begin noticing already laid the essential foundation of AR in
what emerges from states of greater tranquillity. first-session work with clients on early cue
We know from decades of research that anxiety detection and the use of diaphragmatic breath-
interferes with many adaptive processes and ing as a rapid coping response to detected cues.
that relaxation facilitates many forms of Rehearsals of AR take place in the session
performance. The inverted-U nature of arousal whenever the therapist suggests a brief applica-
effects on performance can be described to tion of relaxation in response to observed signs
clients (i.e., anxiety at moderate levels is optimal of increased anxiety. Differential relaxation
but can interfere with performance at very low training is also conducted to facilitate the
and high levels), and they are asked to begin generalization of relaxation skills to daily living.
observing what adaptive behaviors become Clients are taught to relax themselves not
disinhibited or facilitated when they are creating merely when reclining in a comfortable chair
greater states of relaxation for themselves. but even when sitting in upright chairs, walking,
These may include more effective interpersonal and engaging in various common activities. The
behaviors, greater clarity or logic in thought, or therapist tells clients that unneeded muscular
better efficiency and productivity in work. They tension comes in two forms: excessive tension in
are thus invited to explore and discover on their muscle groups required for an activity (e.g.,
own what benefits relaxation may yield. neck muscles needed for holding the head erect)
Behavioral experiments are often useful devices and any tension in muscles that are unnecessary
for demonstrating such effects. For example, for an activity. The goal of differential relaxa-
clients can conduct an ABAB experiment at tion is to identify when either excessive or
work, where ªAº represents their usual state unnecessary tension exists and to let go of that
during work and ªBº represents work done in a tension while continuing to carry out the
more relaxed state. Emotional state as well as activity. In-session practice involves engaging
productivity, accuracy, or efficiency can be in commonly performed activities while identi-
dependent measures for them to assess the fying and relaxing away excessive tension, and
impact of relaxation on their work. between-session practice is encouraged to adopt
a more habitually relaxed lifestyle. Cue-con-
trolled relaxation is often instituted wherein a
6.19.6.4 Applied Relaxation particular word (e.g., ªrelax,º ªcalm,º or a word
taken from meditational focusing devices) is
Merely training clients in a relaxation paired with the release of muscle tension during
technique and asking them to practice it twice PMR and then used as an initial response to
a day are unlikely to yield significant benefits. It initiate applied relaxation in daily coping.
is surprising that before the mid-1980s, many Clients can also be encouraged to use the
therapy trials which included relaxation meth- relaxation response as a method of opening up
ods provided only these elements. Twice-a-day to experience. From a more tranquil center
formal practicing is designed to provide mo- established via relaxation, they are asked to shift
mentary breaks to return oneself to a more their attention more completely and frequently
tranquil state and to further build the skill of to the world around them, taking in the
eliciting relaxation responses and of identifying information which it provides and allowing
what relaxation feels like so that the clients stressful stimuli merely to ªpass throughº them
know what it is that they can usefully move without reacting to such events.
toward. But the real potency of relaxation Finally, clients are told that when stressful
resides in its deployment on a moment-to- events are upcoming, they can think in terms of
moment basis whenever incipient anxiety spirals three phases during which they can apply their
relaxation coping responses: in anticipation of coping responses to typical fear cues. Thus,
the event, during the event, and in recovery after clients are more likely to remember to employ
the event. It is of course useful to deploy their coping responses during daily living given
coping strategies throughout these phases. But associative priming effects from previous ima-
often, especially in the early stages of therapy, ginal rehearsals in therapy.
the most noticeable effect of relaxation applica- ªHierarchyº construction for SCD is less
tions occurs during recovery. It is helpful for detailed than it is in systematic desensitization.
clients to realize that more quickly recovering The therapist helps clients identify both the
from an anxious experience is a desirable event internal cues of their anxiety spirals (somatic,
for increasing their sense of self-control and as a cognitive (especially worry and catastrophic
starting point for more effectively reducing images), and behavioral) and representative
anxiety earlier and earlier in its sequence. As types of external situations where anxiety and
skill in applying relaxation to daily events worry often occur. Images that include both
increases, the therapist and clients can begin to internal and external cues are constructed for
create behavioral homework assignments that use during SCD and only roughly graded from
gradually increase their exposure to stressful, mild to moderate to severe in anxiety-provoking
anxiety-provoking situations in which to apply value. The paragraph below exemplifies one
the methods during these three phases. possible method for conducting a formal SCD
procedure with such images once the client is in
a deeply relaxed state. It includes both therapist
6.19.6.5 Self-control Desensitization patter and procedural instructions.
Because worrying prevents emotional proces- I will now begin to present the images which we
sing and imagery can be an effective method for discussed earlier. Remember to visualize yourself
engaging such processing, imagery exposure as if you are actually in the situation as realistically
techniques could be very useful in the treatment as you can. Also, be sure to raise your index finger
of GAD. The problem is that we do not yet immediately when you first notice the beginnings
of any tension, anxiety, or shift away from the
know what the core fears of GAD clients are. feelings of deep relaxation. Once you have sig-
They are anxious about many situations, naled, be sure to become fully aware of what the
therefore either in vivo or imagery exposure to feelings are like, continue to imagine the scene that
relevant fear-evoking stimuli would be a I am describing, and hold your finger raised until
daunting, potentially excessive therapeutic task. you notice that the anxiety feelings are
Until the central fears and the images that disappearing . . . Visualize yourself at work at your
effectively access those fears can be identified by desk with the boss nearby . . . Imagine that your
future research, self-control desensitization mind is thinking, ªwhat if I make a mistake?º . . .
(SCD) is a helpful intervention tool. SCD was What if I should do something foolish? . . . You can
originally designed to deal with more diffuse feel the anxiety beginning to increase as your mind
is thinking these things . . . The tension and anxiety
anxiety problems for which discrete, graduated are rising as your mind continues to worry about
hierarchies of circumscribed phobic stimuli were acting foolishly . . . Imagine that your heart is
not possible (Goldfried, 1971). In SCD, clients beginning to pound . . . More and more quickly
first focus on relaxation process until they have and intensely . . .
achieved a relaxed state. Next, the therapist asks
the clients to imagine themselves in a situation When the client signals anxiety, or after 60
where internal and/or external anxiety cues seconds of visualization without a signal, in-
occur. Clients signal as soon as actual anxious troduce the coping statements:
experience is elicited by the imagery, and the
therapist then has them imagine coping effec- Just continue to imagine yourself at work at your
tively with the imagined situation by using the desk with the boss nearby but now imagine yourself
relaxation response. Clients signal again as soon relaxing . . . Just visualize yourself relaxing away
as they no longer notice anxious responding, the tension and anxiety, letting go of the worries . . .
and they continue to imagine themselves in the and as you do, imagine that the relaxation is
original situation but effectively coping with it. reducing the speed of your heart, the tension in
Finally, images are terminated altogether, and your muscles . . . Calm and peaceful . . . quiet and
clients return to focusing only on the relaxation relaxed . . . Muscles becoming more and more
deeply and more completely relaxed . . . Heart-
process. The goal of SCD is to have the client racing just melting away, dissipating . . . Breathing
rehearse relaxation applications to the kinds of becoming more and more smooth and regular . . .
situations that they often find problematic. As you imagine yourself at work with the boss
Some degree of extinction process may take nearby and relaxing more and more . . . Just letting
place, but the usefulness of the method probably go of the tension and anxiety and worrisome
resides more in the strengthening of adaptive thoughts and focusing on your work . . .
Continue such patter for another 20 seconds As therapy progresses, the therapist can also
if there is no client signal, then terminate the employ an informal variant of SCD: whenever
image and use periodic relaxation patter to clients begin discussing upcoming stressful
deepen the relaxed state for 20 seconds. If there events or current worries, the therapist can,
is a client signal, continue with the above patter with or without first eliciting a relaxation
(eliminating references to the anxiety cues) for response, ask them to close their eyes and
another 20 seconds beyond the point where the engage in an SCD presentation involving these
anxiety signal is dropped: situations or worries. For worries in particular,
the therapist can merely ask the client to begin
Just continue imagining yourself at work with the worrying, and, once it is established, to let it go
boss nearby . . . Relaxing more and more deeply . . . and relax. Finally, toward the end of therapy,
Muscles continuing to smooth out and unwind . . . formal SCD can be done in two additional ways
Loosening up and becoming more and more that mimic real life events to a closer degree.
comfortably and deeply relaxed . . . Nothing to One involves sequentially presenting several
do but to enjoy the pleasant sensations of relaxa-
different images representing a variety of
tion as the relaxation process continues to take
place as you imagine yourself peacefully at the different stressful events or circumstances with-
office focusing on your work. out the client planning these images beforehand
and with only a single presentation of each
Then instruct the client to stop visualizing image. Thus, an element of surprise typical of
that scene and to continue focusing on the naturally occurring events can be incorporated
relaxation for another 20 seconds: into imaginal rehearsals. The other method is to
present unplanned images that form a seamless
Stop visualizing that scene and go on relaxing . . . story that is both typical of the client's daily
Allowing the relaxation process to continue to take experiences with anxiety and represents a
place now . . . Calm and quiet . . . Peaceful and building accumulation of stressful events.
relaxed . . . Simply enjoy the pleasant feelings of During both methods, the client's task is merely
relaxation and notice how very good it feels to be to engage in ongoing coping in the usual
so deeply and completely relaxed. imaginal way as previously done, but without
breaks in the scene presentations.
Repeat each image a minimum of three times, Once CT (discussed below) has been initiated,
or, if anxiety was signaled, until the client twice self-statements that are anxiety-reducing for a
consecutively no longer signals anxiety within particular client can be added to their repertoire
60 seconds or until the client is able to terminate of coping responses during SCD imaginal
the anxiety fairly quickly (e.g., drops signal exposures. Thus, the client is encouraged to
within seven seconds). use both relaxation responses and perspective
Over time, the therapist introduces more shifts to more accurate ways of thinking about
anxiety cues into the images. Ultimately, the the represented situation as means of coping
client should be able to imagine all cues typical with the anxiety and worry elicited by the
of their anxiety experience, either without scenes.
reacting with anxiety or being able to rapidly
terminate the anxiety. Varied environmental
contexts which incorporate the client's typical 6.19.6.6 Cognitive Therapy
anxiety-provoking situations can be used in the
imagery scenes. Not every cue will have a chance Basic CT for anxiety disorders (Beck &
to be paired with every environmental context. Emery, 1985) involves a fairly straightforward
It is ideal to avoid over-repetition of any one series of steps which can be summarized by a set
context and to cover a representative sampling of questions that the therapist can ask the client:
of contexts and at the same time provide a (i) How are you perceiving the situation
complete coverage of the kinds of internal (what are you thinking, imagining, predicting,
anxiety cues typically experienced by the client. saying to yourself, interpreting, believing)?
Once formal SCD has been initiated in (ii) Is this way of perceiving accurate (what is
therapy, clients are asked to use the technique the evidence)?
at the end of their own daily relaxation practice (iii) If this way may not be true, what
sessions. The client begins by repeatedly alternative ways are there to see the situation
employing the same image that was introduced that have evidence for being more or equally
in the last therapy session. This image should be accurate?
used until it no longer elicits anxiety, at which (iv) Whenever you notice yourself using the
time another image that represents the kinds of old way, why not try viewing the situation with
anxious experience that they have during the one of the alternatives which may be more true,
week can be substituted. or try testing out the perspectives by conducting
experiments during your daily life to get the to their worrying involves daily monitoring of
evidence you need? worry content and the specific predictions they
In initial sessions, the therapist already are making and then observing the actual
helped clients identify the variety of internal outcomes which eventually occur. As men-
cues associated with their anxiety and worry, tioned earlier, when an outcome relevant to a
including thoughts and images, to notice what worry does occur, they rate how bad the
immediate effect these cognitions can have, and outcome was and how well they coped with it.
to notice that their minds and bodies are They are asked to think carefully about each
reacting to something that is not now present actual outcome and what it might mean for
and does not exist in the present. Clients are revising their models of the way things are. By
encouraged to view cognitive events as hypoth- using the worry outcome monitoring method,
eses rather than as facts, as predictions which clients create their own new history of events,
may come true in the future. They are asked to more objectively considered, upon which to
estimate the probability that their feared out- base predictions about the future and ways of
come will actually happen. This question is seeing themselves in the world.
linked to the idea that it is wise for them to avoid Because so many anxieties and worries relate
only probable dangers rather than every con- to social evaluative situations, distancing meth-
ceivable outcome. If the danger does not have a ods are often initially useful, wherein clients are
high likelihood of occurrence, there may be asked to logically analyze the thoughts and
more accurate predictions available. If the predictions of another person rather than of
danger does have a high likelihood, the client themselves (e.g., a friend or acquaintance, a
is asked to rate how well he or she could cope hypothetical stranger, or the therapist role-
with the feared outcome. This question is linked playing someone else). Such distancing reduces
with the idea that we often underestimate our the likelihood of the clients' habitual fear and
ability to cope with predicted negative events. avoidance responses to such material and allows
When analyzing the truth-value of particular them to think more clearly and to reason more
perspectives, clients are asked to consider the accurately.
advantages and disadvantages of this way of As clients engage in logical analysis and
seeing things and to examine the evidence for it. generate more accurate perspectives, they
Quite often, very few advantages can be commonly report that the alternative perspec-
identified, and the anxiety and worry that tive just does not feel true in the way which the
follow from it are obvious to the client. The old view does, even though it is more logical.
probability of something happening in the There is very good reason for this. Worry
future is often best estimated by how frequently contains numerous brief images of negative
it has happened in the past, and the therapist events, and imagery can result in bodily
and client can search personal history to come reactions similar in type and intensity to the
up with a meaningful estimate of the chances for actual occurrence of an event. The more one
the occurrence of the feared event. In addition, imagines catastrophes, the more real they feel.
statistics are sometimes available to specify the Of course images of more likely positive
likelihood of some negative events. outcomes have been occurring far less fre-
Although such traditional methods of helping quently, so the ªfeelingº that these are true is less
clients logically analyze the likelihood that their strong. This is one of the reasons why the
perspectives are accurate or inaccurate are cognitive products from CT are incorporated
useful, the most important therapeutic task into SCD procedure and why realistic images
involves learning to observe the environment on that indicate everything turning out well can be
a daily basis, fully processing the new informa- usefully added toward the end of coping image
tion that is available, and using this information rehearsals.
to construct new models of the way things Although CT begins with specific thoughts
actually are. GAD clients have two character- and images, the therapist and client eventually
istic tendencies which ordinarily counteract identify recurrent, underlying themes that
such a process: focusing on mental illusions of reflect their core beliefs and CT proceeds in a
the past and the future and excessively attending similar fashion using the core beliefs as targets
to the negative features of environmental for intervention. Formal assessment of char-
information. Therapists therefore encourage acteristic thought styles can facilitate the
them to become more objective in their view identification of such schemata. Among the
of events, distinguishing what is actually and factors from the Dysfunctional Attitude Scale
descriptively occurring from their interpreta- (Beck, Brown, Steer, & Weissman, 1991), GAD
tions of events or their guesses about what the clients in the current Pennsylvania State Project
events may mean. One of the best ways of score highest on items referring to fear of
helping them with these tendencies with regard disapproval, dependence on others for their
happiness, and excessively rigid rules about the realistic it is. For example, how do they
way things ªshouldº be. A major goal for CT determine their own perfection? Do they really
with GAD, therefore, involves the creation of need to do everything perfectly, or are there only
greater freedom from others' opinions and more some things which are important? Is it possible
flexible rules by which to judge oneself and for them to be perfect at everything? Could they
others. Central to these is the gradual shifting of still be successful at something if it was not
perspective from an extrinsic to an intrinsic perfect? The therapist can encourage clients to
focus. If clients can learn to attend only to the reword their core beliefs so that they are much
process of their actions and experiences rather more specific. For example, instead of using the
than to the outcomes, less time will be spent above phrase, the client might state, ªI choose to
generating anxiety-provoking cognitions about be the best (mother, teacher, writer) that I can.º
what negative things might happen, and more The latter phrase is much more specific, avoids
time is devoted to attending to the form and social comparison by refocusing on self-com-
quality of the process of living. For example, petition, focuses on the process (trying one's
when people are at work, they can choose to pay best) instead of the outcome, and implies choice.
attention to the external rewards which may A goal of CT for GAD involves the creation
come from the work (and thus create perfor- of more balanced perspectives, that is, the
mance anxiety due to fear of failure), or they can addition of realistic views to older, habitual,
choose to focus on the work itself, its intrinsic negative views. It is not a matter of looking at
meaning, or how it can be done in a beautiful, the world with rose-colored as opposed to
skillful, or joyful manner. Therapists can help brown glasses, but rather of using clear glasses.
clients to identify the specific elements of any With a greater number of perspectives available,
activity or role which can be pleasing or life- clients have choices rather than being deter-
affirming. Rehearsals in SCD of adopting such mined by habit. Once more adaptive cognitions
alternative perspectives can strengthen the are employed with success in their daily lives,
tendency to employ such views on a daily basis. clients can be introduced to one further step:
Clients can have a difficult time at the expectancy-free living. Although planning and
beginning of CT when they are asked to anticipation are necessary human processes
generate alternative ways of thinking or believ- under certain circumstances, much of the time
ing; old habits have often been present for a long expectancies are not necessary. In fact, expec-
time. To facilitate flexible thinking, it is useful tancy can distort the processing of information,
first to practice generating multiple perspectives influence what is recalled from memory, create
on neutral topics where avoidant tendencies are negative mood states during anticipatory per-
less strong. For example, how many ways are iods if its content involves negative predictions,
there to see this pencil? What shapes can we see and can never fully anticipate the way things will
in the cloud formations? How many different turn out anyway. Living with a focus on the
ways do characters in situation comedies on present, processing information from the world
television view the same ªobjectiveº event? Such as it arrives, and trusting one's ability to cope
rehearsals of flexible thinking show clients that with whatever comes down the road are
many ways exist to perceive something and that alternative perspectives potentially useful to
we can create what those ways are for any practice to help the client discover under what
situation. When the therapist eventually ad- circumstances such a lifestyle can be adaptive
dresses anxiety-provoking situations, the first and enjoyable. As an anonymous poet from
step is to generate several possible perspectives Crete wrote, ªI fear nothing; I hope for nothing;
(even humorous ones) without initially judging I am free.º
their reasonableness. The second step is to Because so much of the inner life of the GAD
choose one of the perspectives for application, client revolves around fear of potential bad
using such touchstones as evaluating the things which might happen, a perspective shift
advantages and disadvantages of each perspec- which defines ªbadº in a more relativistic way
tive and judging its likely accuracy based on can be helpful. Certainly we need to evaluate
logic, probability, and evidence. and react to events as they occur partly on the
In defining their core beliefs, GAD clients basis of our immediate judgments about ªgoodº
also often use words which have a strong and ªbad.º But events reflect only relative and
emotional impact and which are vague enough not absolute qualities. For example, the first
to apply to any situation. For example, a author as a teenager spent his life savings on a
common core belief for someone with GAD used car, whose engine died two months later.
might be, ªI must be perfect at everything I do or This was a bad thing. However, it forced him to
I am a failure.º A helpful intervention is to ask find a new job reachable by public transporta-
the client to define what they mean by each word tion. The new job location was where he met his
in the above phrase and to determine how wife, the best thing that has ever happened to
him. We cannot adaptively seek out bad events not be able to cope. Although CT can be seen as
just because they might lead to something good. a very systematic, step-by-step system for
But when either bad or good events happen, it is modifying cognitions, there is no need to follow
useful to realize that new choices are made those steps in textbook fashion. Indeed, overly
available, new doors are opened, and nothing is rigid therapist pursuits can lead to arguments,
absolutely bad. If this is the case, then frustration on the part of both therapist and
anticipations of bad events, so frequently client, and ruptures in the therapeutic alliance
characteristic of GAD, take on a slightly less which make therapy less likely to be beneficial
rigid meaning. (Safran & Segal, 1990). The alternative is to
Decatastrophizing is a useful, traditional CBT reduce the pressure on both parties, de-
method with GAD. Given that clients frequently emphasizing the need to reach a specific out-
fear the worst, identifying what exactly that come in any particular session. The real goal is
would be, the various steps which it would take the creation of a process designed to loosen up
to get to that point, the probability of each step, the client's rigid, habitual modes of thinking and
what alternative perspectives could be adopted, to generate more flexible thinking in a gradual
and what coping resources exist for each step can fashion. There are many specific techniques in
often significantly reduce the fear associated CBT, and the therapist can often move
with the area of concern. If the probability of all smoothly among topics and techniques from
steps occurring together is established to be quite moment to moment in the session. As therapists
low and the likelihood of inability to cope is do so, they watch for a softening of the client's
determined to be nearly nonexistent, clients can reactions to any one of these and pursue any
be encouraged to consider a horse-betting openings which emerge more deeply until signs
analogy. Would they bet their life savings on a of avoidance or resistance are encountered.
horse which has come in last every time in the Such an approach keeps the therapeutic process
past or on a horse which has always won? They flowing without significant obstacles and no
may wish to consider how they are betting their sense of failure.
daily emotional life in a similar context.
Behavioral experiments can be constructed 6.19.7 SUMMARY AND IMPLICATIONS
for clients to conduct between sessions to test FOR FUTURE THERAPY
old and alternative perspectives. Such experi- DEVELOPMENT
ments often provide opportunities for gradu-
ated exposure as well. Asking clients to Basic research has revealed several interre-
approach feared situations to obtain evidence lated features for GAD which fall into three
for beliefs can thus serve a dual purpose. major domains: GAD (i) involves a process
Although circumscribed anxiety-provoking si- (worry) which functions as cognitive avoidance
tuations are not as salient in GAD, clients do to anxiety-provoking material, prevents emo-
often engage in a variety of subtle avoidances tional processing, and thus contributes to the
(Butler, Cullington, Hibbert, Klimes, & Gelder, maintenance of anxious meanings; (ii) has a
1987). One frequent area of avoidance inherent distinctive physiology typified by autonomic
to GAD is cognitive avoidance. For true inflexibility and deficiency in parasympathetic
exposure to be enacted, cognition and behavior tone; and (iii) is associated with specific current
must both reflect an approach. What perspec- interpersonal problems which may have devel-
tive clients adopt during an approach behavior oped partly on the basis of insecure childhood
can make a difference to the extinction process. attachment. Outcome findings suggest that
Fear of bees is an instructive example. Fearful combined CBT is likely to be the most effective
people often swat at bees flying around them, an intrapersonal treatment approach for produ-
irrational, nonapproach act that increases cing long-lasting change, but absolute degree of
rather than decreases the likelihood of being improvement remains unsatisfactory. It seems
stung. Eliminating the swatting and sitting likely that something else must be added to ªbest
motionless until the bee flies away still includes availableº CBT techniques to yield greater and
avoidant behavior (a freezing response). Open- maintained clinical improvement.
ing up one's palm to the bee in an invitation to Prior theorizing about GAD has emphasized
land on the hand is an example of a true the role of habitual, nonlinear, dynamical inter-
approach response in both cognition and action of multiple intrapersonal processes
behavior and is likely to facilitate extinction (attention, thought, imagery, affect, physiology)
and changes in threatening meaning. over time in response to constantly perceived
GAD clients are excellent ªyes, but . . .º threat. The superiority of combined CBT rela-
debaters. They have rich associative networks tive to its elements does suggest that the thera-
which construct an elaborate view of why the peutic targeting of all relevant systems will yield
world is a dangerous place and why they may the greatest change. However, attachment and
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ACKNOWLEDGMENT gery. Behaviour Research and Therapy, 31, 321±324.
Borkovec, T. D., & Mathews, A. M. (1988). Treatment of
This research was supported in part by nonphobic anxiety disorders: A comparison of nondir-
National Institute of Mental Health Research ective, cognitive, and coping desensitization therapy.
Grant MH-39172 to T.D.B. Journal of Consulting and Clinical Psychology, 56,
877±884.
Borkovec, T. D., Mathews, A. M., Chambers, A.,
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6.20
Specific Phobias
PETER MURIS and HARALD MERCKELBACH
University of Maastricht, The Netherlands

6.20.2 SYMPTOMATOLOGY AND EPIDEMIOLOGY 462
6.20.2.1 Case Vignette 462
6.20.2.2 Symptomatology 462
6.20.2.3 Epidemiology 463
6.20.2.4 Genetics 464
6.20.3 DEVELOPMENTAL ASPECTS 464
6.20.4 PATHWAYS TO SPECIFIC PHOBIA 465
6.20.4.1 Classical Conditioning 465
6.20.4.2 Shortcomings of the Traditional Conditioning Approach 466
6.20.4.3 Neoconditioning Model 467
6.20.4.4 Indirect Pathways to Phobia: Modeling and Information 468
6.20.4.5 Disgust Sensitivity 468
6.20.4.6 Retrospective Clinical Studies 469
6.20.5 MAINTENANCE OF PHOBIC FEARS 469
6.20.5.1 Attentional Bias 469
6.20.5.2 Judgmental Bias 470
6.20.5.3 Thought Suppression 470
6.20.6 TREATMENT OF SPECIFIC PHOBIAS 470
6.20.6.1 Exposure-based Treatments 470
6.20.6.2 Eye Movement Desensitization and Reprocessing 471
6.20.6.3 Benzodiazepines 471
6.20.1 INTRODUCTION can be found in the work of seventeenth or

eighteenth century authors such as Descartes
Specific phobias are irrational and persistent and Le Camus.
fears of certain objects or animals. Whereas Since the 1960s our understanding of specific
specific phobia is a relatively recent concept, phobias has steadily increased: it is now
descriptions of the condition to which it refers recognized that learning mechanisms and
have a long tradition in medical history developmental processes play a crucial role in
(Errera, 1962). For example, in his writings, the etiology of specific phobias; there are now
Hippocrates refers to a case of a man who strong indications that certain cognitive pro-
displayed an irrational fear of bridges. Like- cesses contribute to the maintenance of phobic
wise, detailed discussions of phobic symtoms symptoms; and we have a rather clear picture of
461
462 Specific Phobias
how we should treat patients who suffer from a spiders), natural environment type (e.g., water),
specific phobia. The present chapter evaluates situational type (e.g., enclosed spaces), and
these aspects in more detail. blood±injection±injury type (e.g., dental pho-
bia).
The observation that specific phobias tend to
6.20.2 SYMPTOMATOLOGY AND be focused on relatively narrow and circum-
EPIDEMIOLOGY scribed classes of stimuli has led several authors
6.20.2.1 Case Vignette (e.g., Menzies & Clarke, 1995; Seligman, 1971)
to interpret specific phobias in evolutionary
Paula, aged 24, visits a psychologist because terms. Briefly, these authors suggest that the
of her intense fear of spiders. She reports that stimuli feared by phobics reflect the dangers that
she has been afraid of spiders since early our prehistoric ancestors faced in their (pre-
childhood. In the last few months, the spider sumed) Pleistocene savannah environment. As a
fear has become more intense. Until recently, result of natural selection, a readiness to acquire
she lived with her parents, but at the moment she fear of these evolutionary relevant dangers
has her own apartment. She is, however, became genetically coded. Consequently, mod-
seriously considering the possibility of returning ern man still possesses a preparedness (Selig-
to her parents' home. The reason for this is quite man, 1971) or an innate tendency (Menzies &
simple: at her parents', she was able to call her Clarke, 1995) to develop fear of spiders, snakes,
father when she suspected that there was a or blood, for example. Although these evolu-
spider in her bedroom. On these occasions, her tionary accounts have attracted considerable
father inspected the room and removed a spider. attention, other interpretations of the selectivity
Now that she lives in her own apartment, she is of fears do exist. For example, the selectivity of
unable to call upon her father because her specific fears may be a consequence of the
parents live in another town, some 40 miles negative connotations that certain stimuli have
away. Paula is especially afraid of spiders at in our culture (e.g., spiders are commonly seen
night. Consequently, she does not sleep very as dirty [Davey, 1995]).
well. During the day she feels tired and finds it The second crucial element of specific
difficult to concentrate on her work. At home, phobias is concerned with the nature of intense
she is constantly alert and keeps scanning the fear emotions. A good framework for discussing
environment for spiders. Returning to her this point is the three-systems-model proposed
parents' home would probably mean having by Lang (1968). According to this model,
to give up her job as a secretary. emotions such as fear consist of three relatively
independent components: a physiological com-
6.20.2.2 Symptomatology ponent, a subjective component, and a beha-
vioral component. Thus, fear is reflected in
The case vignette presented above illustrates autonomic symptoms (e.g., tachycardia, in-
the criteria for specific phobia that are described creased respiration, etc.), subjective feelings of
in detail in the Diagnostic and statistical manual apprehension, and avoidance or escape beha-
of mental disorders, fourth edition (DSM-IV; vior. In diagnosis or therapy outcome evalua-
American Psychiatric Association, 1994). tion, it is important to measure each of these
Briefly, the DSM-IV stresses that specific components. It should be noted that each
phobia contains three crucial elements: (i) the component can be measured: the physiological
fear is directed at a clearly discernable and component can be monitored with psychophy-
circumscribed stimulus (e.g., spiders), (ii) con- siological techniques (recording of heart rate,
frontation with this stimulus elicits intense fear respiration, etc. [Hugdahl, 1989]), the subjective
and avoidance behavior, and (iii) the fear is component can be quantified with specially
excessive and unreasonable to such a degree that constructed self-report questionnaires (e.g., the
it interferes with daily life. Spider Phobia Questionnaire; Klorman,
As for the first element of the DSM-IV Weerts, Hastings, Melamed, & Lang, 1974),
definition, survey studies have shown that some and the behavioral component can be measured
fears (e.g., fear of spiders or snakes) are far more with standardized approach tasks (i.e., tasks
prevalent than others (e.g., fear of electricity). which require a stepwise approach towards a
Factor analyses have shown that the most phobic object [OÈst, Salkovskis, & HellstroÈm,
prevalent fears can be grouped together in a 1991b]).
relatively small number of distinct categories In passing, it should be noted that not all
(Arrindell, Pickersgill, Merckelbach, Ardon, types of specific phobias display a comparable
& Cornet, 1991; Frederikson, Annas, Fischer, & profile with regard to the three components. For
Wik, 1996). Likewise, the DSM-IV recognizes instance, both animal phobia and blood±
four types of specific phobias: animal type (e.g., injection±injury phobia are accompanied by
Symptomatology and Epidemiology 463
subjective reports of distress. However, whereas the phobic stimulus, a fear response is already on
in animal phobia distress usually takes the form its way. This might explain why phobics
of fear, blood±injection±injury phobia is asso- experience their fears as automatic and un-
ciated with strong subjective feelings of disgust controllable. Support for OÈhman's (1993)
and repulsion (e.g., Page, 1994). Also, con- hypothesis comes from a study in which it was
frontation with the phobic stimulus elicits shown that subliminal presentations of phobic
sympathetic activation (e.g., tachycardia) in slides (i.e., spiders and snakes) are sufficient to
animal phobia, but parasympathetic activation elicit autonomic responding in phobic but not in
(e.g., bradycardia) in blood±injection±injury control subjects (OÈhman & Soares, 1994). This
phobia. That is, although exposure to the finding fits well with the animal studies of
phobic stimulus produces heightened arousal LeDoux (1992). This reseacher found evidence
in animal phobics, lowered arousal that may for a subcortical fear pathway linking the
result in fainting is seen in blood±injection± thalamus with the amygdala. The thalamo±
injury phobia (Thyer, Himle, & Curtis, 1985). amygdala pathway is a ªquick and dirtyº trans-
As far as the content of subjective fear is mission route in which the thalamus carries out a
concerned, there are also major differences crude analysis of the sensory input and then
between situational phobia (especially claus- activates the amygdala, which, in turn, generates
trophobia) and animal phobia. Subjective fear an emotional response. According to LeDoux
in claustrophobia is not only focused on danger, (1992, p. 276), this pathway has adaptive value:
but also on anxiety expectations (e.g., fear of ªthe thalamo±amygdala system might be espe-
going crazy) and bodily sensations. The latter cially useful as a processing channel under
components are less prominent in animal conditions where rapid responses are required to
phobias (Craske, Mohlman, Yi, Glover, & threatening stimuli. In such situations, it may be
Valeri, 1995). more important to respond quickly than to be
The third characteristic of specific phobias certain that the stimulus merits a response.º
that requires some elaboration is their irrational Thus, one may speculate that in specific phobia,
nature. The patient suffering from, say, an learning experiences have affected the thalamo±
intense spider phobia, readily admits that his or amygdala pathway in such a way that it is
her fear is excessive. Nevertheless, he or she is oversensitive to certain phobic cues.
unable to inhibit fear responses when exposed to
spiders. How can one account for this failure to
control fear responses? A first possibility is that, 6.20.2.3 Epidemiology
although the patient is convinced about the
irrationality of the phobia when questioned in Epidemiological studies indicate that the life-
the absence of the feared stimulus, the presence time and the 12-month prevalence of specific
of this stimulus may activate unreasonable and phobias are as high as 11.3% and 8.8%,
frightening danger expectations. There is some respectively (Kessler et al., 1994). These data
empirical support for this line of reasoning. For suggest that specific phobia is one of the most
example, De Jongh, Muris, Schoenmakers, and frequent mental disorders.
Ter Horst (1995a) asked dental phobics to rate In his community study among women,
how much they were inclined to believe highly Costello (1982) found that animal fears (in-
unrealistic dentist-related propositions. Data cluding fear of dogs, snakes, etc.) were the most
showed that in anticipation of dental treatment, prevalent, followed by nature (e.g., heights),
dental phobics report various catastrophic and mutilation (e.g., injections) fears. In effect,
beliefs about the dentist (e.g., dentists are often animal fears occurred in nearly 43% of the
impatient), the treatment (e.g., everything will women. Whether these fears represent clinical
go wrong), and their own reactions (e.g., I can't phobias is not clear. Employing the DSM-IV
control myself). Such catastrophic expectations criteria for specific phobias, Frederikson et al.
also have been described in other types of (1996) found that situational and environmen-
specific phobia (e.g., Arntz, Lavy, Van den tal phobias had the highest point-prevalence
Berg, & Van Rijsoort, 1993; Thorpe & rate (13.2%), followed by animal phobias and
Salkovskis, 1995). blood±injection±injury phobias (7.9% and
A somewhat different stance is taken by 3.0%, respectively).
OÈhman (1993). According to OÈhman, phobic Most specific phobias are diagnosed more
stimuli are analyzed by fast and subcortical frequently in women than in men. This is
information processing routines. These infor- especially true for animal phobias and situa-
mation processing routines provide a rough tional and environmental phobias, but less so
analysis of the stimulus and then initiate an for blood±injection±injury phobias (Frederik-
immediate fear response. Consequently, even son et al., 1996). There are strong indications
before the phobic patient becomes fully aware of that this sex difference in the prevalence of
specific phobias cannot be explained fully by in childhood. This finding is underlined by

assuming that it is more socially permissible for surveys of subclinical fears among children. In
women to report fear than for men (Cornelius & an early study of MacFarlane, Allen, and
Averill, 1983). Probably, other predisposing Honzik (1954), it was found that only a small
factors (such as sex hormones, see discussed minority of a large sample of children
below) play a significant role in the skewed sex (N=1096) displayed no fear reactions. A similar
distribution of fears and phobias. finding was reported by Lapouse and Monk
With regard to the natural course of specific (1959). These authors found, for example, that
phobia, Wittchen (1988, p. 14) summarized the in 6±8 year olds, nearly 44% had a mild fear of
results of his longitudinal community study as blood. Altogether, it appears that mild to
follows: ªThe natural course of simple phobias moderate fears are quite common in childhood.
is in the majority of cases chronic and can be In this connection, there are several points that
characterized by the persistence of mild rather deserve comment.
than severe symptoms of anxiety over decades. First, studies evaluating specific fears in
Only 16% remitted completely over the follow- children have consistently found that girls
up period of 7 years: thus, only very few report more fears than boys (Ollendick, Yule,
spontaneous remissions could be observed.º In & Ollier, 1991). Second, the mild fears seen in
passing, it should be noted that specific phobia children often represent transient developmen-
often occur as an additional diagnosis in panic tal phenomena. That is to say, childhood fears
disorder and generalized anxiety disorder (De follow a predictable course (Marks, 1987). For
Ruiter, Rijken, Garssen, Van Schaik, & Kraai- example, Bauer (1976) found that fear of ghosts
maat, 1989). and fear of animals are common in children
aged 4±8. In contrast, fear of injury is more
characteristic of children aged 10±12. According
6.20.2.4 Genetics to Bauer, these fluctuations in childhood fear
are closely tied to cognitive development.
Several large-scale twin studies have been
Younger children would rely on global percep-
carried out to explore to what extent genetic
tion and animistic concepts in interpreting
factors predispose to phobic fear (e.g., Kendler,
cause±effect relationships. This would explain
Neale, Kessler, Heath, & Eaves, 1992). Briefly,
why their fears are directed at ghosts and
these studies have found that the genetic
animals. Bauer's emphasis on cognitive devel-
contribution to specific phobias is significant,
opment makes sense. For example, the visual
though small. Moreover, the genetic factors
cliff phenomenon (fear of heights) that typically
underlying specific fears are of a general nature.
occurs in young babies between four and nine
That is, there is no inheritance of a specific fear,
months has long been interpreted as a prototype
but inheritance of a general trait that predis-
of a genetically based fear. However, experi-
poses to neurotic complaints. In some cases
ments show that this phenomenon critically
these complaints amount to a specific phobia,
depends on locomotor development in infants
but in other cases the complaints take the form
(Bertenthal & Campos, 1984). A (social)
of social phobia, agoraphobia, and so on
developmental interpretation of the different
(Andrews, Stewart, Morris-Yates, Holt, &
onset ages of fears and phobias is also presented
Henderson, 1990).
by OÈhman (1987), who points out that animal
fears typically occur during a developmental
6.20.3 DEVELOPMENTAL ASPECTS phase in which young children become more
independent from their parents. From an
In general, specific phobias are characterized evolutionary perspective, it may be assumed
by early onset ages. For example, OÈst (1987) that during this phase, children are vulnerable to
found mean onset ages of seven and nine years predators. The sensitivity of young children to
for animal and blood±injury±injection phobias, phobogenic animal stimuli would therefore
respectively. An early onset is also found in have survival value.
natural environment phobias. For example, a Third, fear rank orders based on what
considerable percentage of height-fearful sub- children indicate as their most feared object
jects report that their fear has always been have demonstrated that typical topics of adult
present (Menzies & Clarke, 1993). It should be specific phobias are also very common in
noted, however, that situational fears such as children. For example, snakes and spiders
claustrophobia differ from this pattern in that feature high in fear rank orders of children
they have a later onset. For instance, OÈst (1987) (Muris, Merckelbach, Meesters, & Van Lier,
reported a mean onset age of 20 years for his 1997). This suggests that the content of child-
sample of claustrophobics. Nevertheless, a hood fears resembles that of specific phobias in
substantial proportion of specific phobias begin adults.
Pathways to Specific Phobia 465
Fourth, although it is clear that the majority The basic finding of Watson and Rayner, that
of childhood fears disappear spontaneously, fear can be conditioned by pairing a neutral CS
there are also indications that in a subgroup of with an aversive or traumatic UCS, has been
children, the specific fears persist (Ollendick, replicated many times. For example, in a study
1979). Thus, the critical question to be asked is by Campbell, Sanderson, and Laverty (1964),
why in some cases, specific fears appear to subjects listened to a tone (CS) that was followed
continue from childhood into adulthood. Part by an injection of scoline. This injection pro-
of the answer probably lies in the heritability duced a temporary respiratory paralysis (UCS)
factor associated with fear. For example, and, consequently, intense fear (UCR). Even
Stevenson, Batten, and Cherner (1992; p. 984) weeks after this single conditioning trial, subjects
found suggestive evidence that the influence of reacted with strong autonomic responses (CR)
this heritability increases with age: ªas children to isolated presentations of the tone (i.e., the tone
move through adolescence this would lead to was not followed by paralysis).
avoidance behaviour which would reinforce the Although laboratory findings such as these
fearfulness of these individuals genetically illustrate that conditioning processes can, in
prone to fearfulness. The net effect will be an principle, produce phobia-like fears, they do not
increasing significance of genetic influences over establish that in everyday life, classical con-
individual differences with age.º Furthermore, ditioning is the cause of phobias. However,
research suggests that apart from genetic there is evidence to support the notion that
factors, three types of learning might contribute classical conditioning processes do operate
to the persistence of childhood fears, namely outside the laboratory chambers. For example,
classical conditioning, modelling, and negative Kuch, Cox, Evans, and Shulman (1994)
information transmission. reported that of 55 survivors of road vehicle
accidents (UCS), 21 (38%) developed a phobia
of driving (CS). Furthermore, 80% of the
6.20.4 PATHWAYS TO SPECIFIC PHOBIA subjects with a severe weather phobia indicated
6.20.4.1 Classical Conditioning that their fear began after experiencing a severe
storm (Westefeld, 1996). Likewise, choking
Ever since Watson and Rayner's (1920) little phobia is nearly always the result of a traumatic
Albert study, researchers have tried to explain incident in which the patient chokes on, for
the etiology of specific phobias in terms of example, a fishbone (Greenberg, Stern, &
aversive classical conditioning. Little Albert was Weilburg, 1988).
an infant who initially showed no fear of live The classical conditioning model of specific
animals. However, he did react with fear phobias explains why persons react with
whenever noise was produced by stricking a subjective fear and physiological arousal when
steel bar with a hammer. Watson and Rayner they are exposed to the phobic CS. It does not,
then exposed Albert to a white rat and produced however, account for the persistent avoidance
a loud noise with the hammer and steel. Albert behavior that phobics display. The influential
was given six trials of white rat and noise. two-stage theory of Mowrer (1960) attempts to
Eventually, little Albert reacted with crying and incorporate this point. Briefly, Mowrer's theory
avoidance as soon as he was confronted with the assumes that the development of phobias
white rat. Watson and Rayner argued that the involves two stages. During the first stage, a
little Albert case illustrates that phobias can be pairing of a neutral CS and an aversive UCS
understood as the outcome of a Pavlovian or results in a conditioned fear response to the CS.
classical conditioning process. In technical During the second stage, the person learns that
terms the phobic object (e.g., a rat) is a fear responses to the CS can be reduced by
conditioned stimulus (CS) that initially elicits avoiding the CS. A reduction in fear levels that
no fear. An aversive event (e.g., a loud startling follows avoidance is experienced as a positive
noise) is an unconditioned stimulus (UCS) that, state. Consequently, avoidance behavior is
by virtue of its biological characteristics, reinforced and in time becomes an integral part
reliably induces a fear response. This fear of the phobic fear. Again, research shows that
response is therefore termed the unconditioned the scenario depicted by the two-stage theory
response (UCR). If the CS is paired with the works in the laboratory. Thus, when subjects
UCS, a fear response occurs and becomes are confronted with pairings of light (CS) and
associated with the CS. Thereafter, the CS is shock (UCS) and then are given the opportunity
able to elicit a full blown fear response, even in to react with an escape response every time the
the absence of the UCS. The fear response has CS appears, persistent avoidance responding
then become a conditioned response (CR) to the occurs (Malloy & Levis, 1988).
CS and, consequently, the CS has turned into a The two-stage theory of phobic fear has
phobic object. straightforward treatment implications. Ac-
cording to this theory, avoidance behavior These and other shortcomings of the tradi-
maintains phobic fear because it prevents tional conditioning approach to phobias paved
prolonged exposure to the phobic object. the way for two types of revision. The first type
Consequently, phobic subjects have no oppor- of revision stressed that conditioning concepts
tunity to experience that the phobic CS is no should be connected with biological notions in
longer accompanied by an aversive UCS. The order to understand the etiology of phobias.
treatment lesson to be learned from this is that The aforementioned preparedness hypothesis
one should confront phobic subjects with their (Seligman, 1971) is a good example of such a
phobic CS while ensuring that they do not react biologically oriented revision. This hypothesis
with avoidance to this CS. This strategy, known assumes that conditioning interacts with evolu-
as exposure therapy, has proven to be very tionary processes to produce phobic fear. Thus,
successful in the treatment of specific phobias aversive events (UCSs) in the context of
(Marks, 1987; OÈst, 1989). evolutionary recent objects (e.g., electricity)
would not produce a phobic fear, whereas such
events in the context of evolutionary relevant
6.20.4.2 Shortcomings of the Traditional items (e.g., snakes) would easily give rise to a
Conditioning Approach phobic fear. Several experiments have tested this
idea in the laboratory. By and large, the results
In the 1970s, several authors drew attention of these experiments are disappointing in that
to the fact that the classical conditioning model they found no evidence for a connection
of phobias and its extension, Mowrer's two- between ease of conditioning and evolutionary
stage theory, suffered from a number of serious relevance of the CS (Hugdahl & Johnsen, 1989).
shortcomings (Eysenck, 1979; Rachman, 1977). Another attempt to revise the conditioning
First, the conditioning approach fails to explain model along biological lines proposes that the
why specific fears are nonrandomly distributed. phobogenic effects of CS±UCS pairings interact
Indeed, from a conditioning point of view, one with the neurohormonal state of the organism
would expect that each object can become a (Kelley, 1987). In Kelley's words: ªneuroses=
phobic stimulus (CS), provided that it is conditioning 6 neurohormonesº (p. 403). More
followed by an aversive event (UCS). As specifically, Kelley argues that high levels of
previously stated, this is obviously not the case. adrenocorticotropic hormone (ACTH) and
For instance, fear of snakes occurs more often vasopressin enhances the effects of CS±UCS
than fear of electricity, although there is no pairings whereas high levels of endogenous
obvious reason to suspect that snakes are more opioids (i.e., endorphins) attenuate these effects.
frequently associated with UCSs than electricity Accordingly, individual differences in neuro-
(Agras, Sylvester, & Oliveau, 1969). hormonal levels might explain why, for exam-
Second, in the literature, excellent illustra- ple, an automobile accident produces a driving
tions can be found of aversive situations (UCSs phobia in some people, but not in others (Kuch
e.g., air raids) in which, contrary to all et al., 1994): some subjects are more vulnerable
predictions that can be derived from the to CS±UCS pairings because they habitually
classical conditioning model, people did not have heightened levels of ACTH and vasopres-
acquire phobic fears (e.g., Saigh, 1984). In the sin and/or lowered endorphin levels. Although
aforementioned study of Kuch et al. (1994) not it is evident that phobic fear is accompanied by
all accident survivors developed a fear of elevated or reduced levels of certain (neuro)-
driving. Similarly, there is abundant evidence hormones (Cameron & Nesse, 1988), Kelley's
to show that aversive experiences (UCSs) with proposal has not been put to a direct test. All
spiders, dentists, or dogs do not give rise to that one can conclude from the evidence at hand
spider phobia, dental phobia or dog phobia, is that lowering the endorphin levels by applying
respectively (Merckelbach, Arrindell, Arntz, & naltrexone (i.e., an opioid antagonist) intensifies
De Jong, 1992; Lautch, 1971; DiNardo, Guzy, fear in subjects who are already phobic
& Bak, 1988). Clearly, then, trauma (UCS) (Merluzzi, Taylor, Boltwood, & GoÈtestam,
without subsequent phobia occurs. 1991; Arntz, Merckelbach, & De Jong, 1993).
Third, over the years, it has become clear that A related line of research has stressed the
not all specific phobias can be traced back to involvement of sex hormones in the acquisition
a confrontation with a traumatic or aversive of phobic fear. For example, in their review
event (UCS). In other words, some people Cameron and Nesse (1988, p. 291) conclude that
develop a fear response to a CS, although this ªsex hormone fluctuations in women during the
CS has never been paired with a UCS (Wolpe, menstrual cycle may be related to changes in
Lande, McNally, & Schotte, 1985). In other anxiety levels, although fluctuations have not
words, phobia without preceding trauma (UCS) always been observed.º Interestingly, Van der
occurs. Molen, Merckelbach, and Van den Hout (1988)
Pathways to Specific Phobia 467
found that pre-menstrual women show an mechanism of latent inhibition is relevant when
increased susceptibility to fear conditioning. one tries to understand how trauma (UCS)
Sex hormone fluctuations may also explain why without phobia can occur. These researchers
specific phobias are more often found in women found that traumatic encounters with dogs are
than in men. reported by both subjects with fear of dogs and
subjects without fear of dogs. However, the
latter group reported more previous nonaver-
6.20.4.3 Neoconditioning Model sive contacts with dogs. In other words, the
nonfearful subjects had experienced many
The second type of revision of the classical occasions on which dogs (CS) did not attack.
conditioning model is more cognitively or- This suggests that in the nonfearful group,
iented. Advocates of this approach point out latent inhibition helped to minimize the effects
that conditioning is not the blind, reflexive of fear conditioning (Davey, 1989a; De Jongh,
process that it is often assumed to be (Van den Muris, Ter Horst, & Duyx, 1995b).
Hout & Merckelbach, 1991). The critical A second phenomenon that must be con-
question to be asked is: what exactly happens sidered is called UCS inflation (Davey, 1989b).
during conditioning? Take the example of little Briefly, this phenomenon refers to a situation in
Albert. Did conditioning result in a reflexive which subjects are exposed to pairings of a CS
connection between the white rat stimulus (CS) and a mild UCS. As a result of this, subjects
and the fear response (CR)? Or did little Albert acquire an S±S association. However, given the
learn that the white rat stimulus (CS) predicts low intensity of the UCS, this S±S association
the onset of the noise stimulus (UCS) and was it leads to a weak conditioned fear response (CR).
this knowledge that elicited a CR? The first Now, the following may happen: if subjects
scenario is called S-R learning; the second during a next phase learn that the UCS is
scenario is known as S-S learning. There are nevertheless dangerous, this postconditioning
good reasons for believing that, in humans, S-S information will lead to an inflation of the UCS
learning is the most common classical con- value. Consequently, the conditioned fear
ditioning scenario. That is to say, conditioning response will grow in strength. A clinical
is usually a cognitive process during which one example taken from White and Davey illus-
learns that the CS predicts the UCS (Rescorla, trates how this kind of scenario can account for
1988). It is important to note that an S-S cases in which conditioned fear emerges without
approach (i.e., the neoconditioning model) has pertinent trauma:
a number of interesting ramifications and is able
to avoid some of the inadequacies of the an individual may witness an unknown person die
traditional conditioning model (Rachman, of a heart attack on a bus or a train. On future
1991). Two specific aspects of the neocondition- occasions, riding on public transport may evoke
ing model deserve comment. memories of this incident but no anxiety. . . .
First, the neoconditioning model emphasizes Subsequently, however, that individual may be
the phenomenon of latent inhibition. Suppose a present when a close friend or relative dies of a
heart attack, thus inflating the aversive properties
subject has extensive experience with a CS (e.g.,
of heart attacks. This may then give rise to acute
light) that is not followed by an aversive UCS. anxiety when riding on public transport. In this
What will happen when this subject is later particular scenario, public transport has never
exposed to a new situation in which the CS is been directly associated with anxiety-eliciting
suddenly accompanied by a painful UCS (e.g., trauma, but the public transport phobia results
electric shock)? Will the CS now elicit a from a prior learned association between public
conditioned fear response? The answer is no. transport and heart attacks, and subsequent
Laboratory experiments show that it is difficult independent inflation of heart attacks as aversive
to condition fear responses to a familiar CS that events. (White & Davey, 1989, p. 165)
was formerly never associated with an aversive
UCS (Booth, Siddle, & Bond, 1989). Recall To recapitulate, neoconditioning concepts
that, during conditioning, subjects learn that a such as latent inhibition and UCS inflation
CS is the predictor of a UCS. If the subject has can deal with some inadequacies of the tradi-
experienced a number of times that the CS tional conditioning approach. More specifi-
predicts nothing, an incidental co-occurrence of cally, latent inhibition can explain why UCS
the CS with an aversive UCS is not powerful trauma does not always lead to phobia, whereas
enough to make the subject believe that the CS UCS inflation can explain why phobia without
has changed into a predictor of the UCS. In pertinent UCS trauma is possible. Apart from
other words, prior experiences with the CS that, these concepts have implications for the
inhibit fear conditioning. A study by Doogan treatment of phobias (Davey, 1992). For ex-
and Thomas (1992) nicely illustrates that the ample, one may use the principle of latent
inhibition as a way of producing immunization experimental studies on the fear-evoking char-

against the effects of subsequent CS±UCS trials. acteristics of negative information, social psy-
Giving dental patients a series of painless sham chological studies show that subjects assign
treatments will probably reduce the likelihood more value to negative than to positive
that a subsequent painful treatment results in a information. There might be good evolutionary
dental phobia (De Jongh et al., 1995b). As reasons for this asymmetry (Pratto & John,
another example, the principle of UCS inflation 1991).
suggests that, during treatment, it might be Assuming that modeling and negative in-
worthwhile to systematically devaluate the formation transmission are closely tied to
UCS. In the case of dental phobia, this could familial interactions, one would expect that
mean that one stresses the point that aversive there is a familial aggregation of specific
experiences result in healthy teeth. phobias. A study by Fyer et al. (1990) shows
this to be the case. These researchers found, for
example, that 31% of the relatives of specific
6.20.4.4 Indirect Pathways to Phobia: Modeling phobia probands as compared to 11% of
and Information control relatives had a life-time diagnosis of
specific phobia. Although this study did not
The classical conditioning pathway to fear distinguish between different etiological me-
assumes that the subject has direct experience chanisms (genetic inheritance, modeling, etc.),
with the CS and the UCS. This is true for its results are consistent with the idea that
straightforward conditioning in which a CS is modeling and information do operate in
paired with a traumatic UCS, as well as for families. Likewise, a recent study by Muris,
subtle conditioning scenarios such as latent Steerneman, Merckelbach, and Meesters (1996)
inhibition and UCS inflation. However, there demonstrated that fears reported by children are
are cases in which subjects develop a specific a function of the extent to which mothers
phobia although they have no history of direct express their own fears in the presence of their
experience with the CS (i.e., phobic object) and/ children. This association was independent of
or UCS (Rachman, 1991). In these cases, the influence of trait anxiety levels in mothers.
indirect pathways of fear acquisition might play
a pivotal role. Rachman (1991) provides a
detailed description of two indirect pathways 6.20.4.5 Disgust Sensitivity
that are important in this context: modeling
(imitation or vicarious transmission of fear) and Disgust sensitivity is believed to play a role in
negative information. the etiology of certain types of specific phobias,
The modeling pathway assumes that phobic especially animal phobias (Matchett & Davey,
fears can be acquired by watching parents or 1991). For example, several studies have found
peers reacting fearfully to a stimulus (e.g., a that spider-phobic subjects have a higher disgust
spider). This assumption is supported by animal sensitivity than nonphobic subjects (Merckel-
and human laboratory studies. For example, bach, De Jong, Arntz, & Schouten, 1993).
Cook and Mineka (1989) found that rhesus Furthermore, spider-phobic subjects consider
monkeys can acquire a fear of snakes through spiders to be more disgusting than do non-
watching videotapes of two model monkeys phobic subjects (De Jong, Andrea, & Muris,
reacting fearfully to toy snakes. Likewise, 1997). Finally, behavioral treatment results in a
Hygge and OÈhman (1978) demonstrated that parallel decline of fear of spiders and spiders'
subjects respond with sympathetic activation to disgust-evoking status (De Jong et al., 1997).
pictures of, for example snakes when they have These data indicate that there is a clear
previously watched others reacting fearfully to association between disgust and disgust sensi-
these pictures. The reverse is also true: the tivity on the one hand, and clinical manifesta-
pioneers of behavior therapy already knew that tions of spider fear on the other hand.
it is possible to eliminate specific fears by It should be noted that most studies on
presenting nonfearful models and enhancing disgust and phobia are correlational in nature,
social learning through modeling (Kornfeld, and that they do not rule out the possibility that
1989). fear enhances disgust and/or disgust sensitivity
It seems obvious that negative verbal in- rather than vice versa. However, an experiment
formation about certain stimuli such as that of Webb and Davey (1992) indicates that fear
provided by books, television, or significant can be causally affected by disgust. In that
others may give rise to fear of these stimuli. If study, it was found that exposure to revulsive
this was not the case, prevention programs material (such as video scenes of a medical
concerned with smoking or AIDS would make operation) leads to an increase in fear of, for
no sense. Although there is a paucity of example, spiders or snakes.
Maintenance of Phobic Fears 469
6.20.4.6 Retrospective Clinical Studies phobic fear: avoidance would minimize direct
and prolonged contact with the phobic object
Several studies have examined to what extent and, hence, phobics would not have the
the aforementioned pathways to fear play a role opportunity to learn that the CS is a neutral
in the etiology of specific phobia (Kleinknecht, object or otherwise extinguish fear response.
1994; Merckelbach et al., 1992; OÈst, 1987). Most Although the role of avoidance behavior in
of these studies have used the Phobic Origin the conservation of fear seems self-evident,
Questionnaire (POQ; OÈst & Hugdahl, 1981), a there are other mechanisms that are highly
self-report instrument that asks phobic patients relevant in this context. These mechanisms are
to indicate to what degree their phobia devel- cognitive in nature and have been the object of
oped along a direct (i.e., conditioning) and/or extensive research in the past years (Dalgleish &
an indirect (i.e., modeling, negative informa- Watts, 1990; Mineka & Sutton, 1992). There is
tion) pathway. A potential problem in these agreement among most researchers in this field
studies is that phobics are invited to provide a that pathological anxiety (e.g., specific phobia)
retrospective judgement as to the cause of their is not accompanied by a general cognitive
complaints. With this type of research strategy, dysfunction. In other words, it is not the case
all kinds of biases (e.g., memory distortions) that pathological anxiety is associated with
may occur. On the other hand, Brewin, deficits in memory, attention, motor function
Andrews, and Gotlib (1993) have summarized and so on. Instead, cognitive dysfunctions in
evidence to show that claims about the specific phobias are restricted. First, phobic
unreliability of retrospective reports are often subjects show evidence of dysfunctions in
exaggerated. attentional and inferential (i.e., judgmental)
Several interesting findings have emerged processes. In contrast, depressive patients
from the POQ studies. First, although each of exhibit dysfunctions in memory rather than
the three pathways is represented in the various attention or judgment (Mineka & Sutton, 1992).
types of specific phobia, there are large Second, the attentional and judgmental biases
differences between the types. For example, that characterize phobias are domain specific.
animal phobics and blood±injection±injury That is to say, these biases become apparent if
phobics more often ascribe their fears to and only if subjects are confronted with fear-
modeling and negative information than claus- relevant stimuli (e.g., the word spider in case of a
trophobics. In contrast, the conditioning path- spider phobic subject).
way is more pronounced in claustrophobia than
in animal, blood±injection±injury illness or
height phobia (Menzies & Clarke, 1993; OÈst,
1987). Interestingly, OÈst (1987) found evidence 6.20.5.1 Attentional Bias
to suggest that modeling and negative informa- Attentional bias refers to the phenomenon of
tion are associated with an early onset age. hyperattention to threatening material. One
Second, several studies (Merckelbach, Arntz, & frequently employed technique for demonstrat-
De Jong, 1991; Ollendick & King, 1991) have ing attentional bias is the modified Stroop color
found that fearful subjects often report more task. This task requires subjects to name the
than one pathway. There are even indications color of a word while ignoring the meaning of
that subjects with mixed pathways (e.g., con- that word. A consistent finding in Stroop
ditioning and modeling) have higher levels of studies with anxious patients is that their color
fear. Finally, the three pathways to fear are also naming of threatening words is slower than that
found in fearful and phobic children aged 9±14 of neutral words (Eysenck, 1992). For example,
years (Merckelbach, Muris, & Schouten, 1996; spider phobics display retarded color-naming
Ollendick & King, 1991). This suggests that times when they are confronted with spider-
these etiological mechanisms do, indeed, oper- related words (e.g., web), but not when they
ate during the early developmental phases. have to color name neutral words (e.g., car).
This is because spider phobics automatically
direct their attention to the content of the
6.20.5 MAINTENANCE OF PHOBIC threatening words and this interferes with their
FEARS main task (i.e., color naming). Note that the
phenomenon of attentional bias accords well
Specific phobias are acquired on the basis of with OÈhman's (1993) hypothesis of a ªquick and
direct or indirect learning pathways. But how dirtyº subcortical transmission route of phobic
are phobic fears maintained, once they are information (discussed above). Interestingly,
acquired? As mentioned earlier, Mowrer's the attentional bias may disappear in success-
(1960) two-stage model suggests that avoidance fully treated spider phobics (Watts, McKenna,
behavior is responsible for the conservation of Sharrock, & Trezise, 1986). As to the clinical
consequence of attentional bias, it seems likely 6.20.5.3 Thought Suppression

that an increased focus on danger and threat
stimuli perpetuates phobic fear: attentional bias As mentioned earlier, phobic patients are
implicates an increased encoding of threatening frequently disturbed by anxiety-arousing
material and this, in turn, will elevate fear levels thoughts. To avoid feelings of discomfort,
(Mineka & Sutton, 1992). phobic patients may try to suppress such
thoughts. However, research has shown that
thought suppression has paradoxical effects.
That is, the effort ªnot to think aboutº a
6.20.5.2 Judgmental Bias particular thought may, in fact, lead to the
Two types of judgmental bias probably play a continuation of that thought (Wegner, Schnei-
role in the maintenance of specific phobia. The der, Carter, & White, 1987).
first is covariation bias, the tendency to over- Several authors (Salkovskis, 1989; Wegner,
estimate the association between phobic stimuli 1989) have put forward that thought suppres-
and aversive outcomes (Tomarken, Mineka, & sion might play a role in the etiology and
Cook, 1989). The experimental demonstration maintenance of anxiety disorders such as
of covariation bias in phobias is straightfor- specific phobias. In a recent study, Muris, De
ward. Phobic and normal subjects are shown a Jongh, Merckelbach, Postema, and Vet (in
series of slides consisting of fear-relevant (e.g., press) found some evidence for this claim. In
spiders) and fear-irrelevant pictures (e.g., flow- their study, effects of thought suppression in
ers). Slide offset is followed by one of three phobic and nonphobic dental patients were
outcomes: an aversive shock, a tone, or nothing. examined. The results were as follows. First, as
Fear-relevant and fear-irrelevant pictures are expected, phobic patients reported higher levels
equally often followed by each of the outcomes. of intrusive and negative thinking during dental
After the series of slides, subjects are asked to treatment than nonphobic patients. Second,
estimate the contingencies between slides and phobic patients tried harder to suppress their
outcomesÐif a spider picture appeared, how negative thoughts than nonphobic subjects.
great was the chance that this picture was Finally, in the nonphobic group, suppression
followed by a shock? Under these experimental resulted in increased levels of anxiety and
conditions, phobic subjects systematically over- intrusive thinking. Altogether, the findings
estimate the contingency between phobic sti- suggest that thought suppression is related to
muli and aversive outcomes. Again, in pathological manifestations of dental fear. That
successfully treated spider phobics, the covaria- is to say, suppression intensifies fear in
tion bias disappears (De Jong, Merckelbach, nonphobic subjects, whereas it appears to be
Arntz, & Nijman, 1992). De Jong, Van den part of the habitual ªcopingº style in phobic
Hout, and Merckelbach (1995) found a strong patients.
and positive correlation between residual cov-
ariation bias in treated spider phobics and
relapse: the stronger the (post-treatment) over- 6.20.6 TREATMENT OF SPECIFIC
estimation of the contingency between spider PHOBIAS
picture and aversive shock, the higher the spider 6.20.6.1 Exposure-based Treatments
fear at two-year follow up. The implication of
this covariation bias is clear: phobics have a Exposure in vivo is the treatment of choice for
tendency to attribute aversive experiences to the specific phobias (Marks, 1987; Rachman, 1990).
phobic object and this, in turn, will sustain Exposure treatment involves graded and pro-
phobic fear. longed confrontation with the phobic object.
A second judgmental bias that may occur in Meanwhile, the therapist encourages the patient
specific phobias is a style of reasoning known as to approach the phobic object and to refrain
ex consequentia inference. Like other people, from avoidance behavior. Exposure is often
phobics believe that dangerous situations elicit combined with other techniques: modeling by
anxiety. However, unlike many nonphobic the therapist in the case of animal phobias (OÈst,
subjects, spider phobics seem to believe that 1989), applied tension to prevent fainting in the
anxiety symptoms imply the presence of danger, case of blood±injection±injury phobias (OÈst,
such as dangerous spiders (Arntz, Rauner, & Fellenius, & Sterner, 1991a), and cognitive
Van den Hout, 1995). The ex consequentia interventions to correct catastrophic misinter-
inference probably serves to legitimize the pretations of bodily symptoms in the case of
phobic fear and, thus, may maintain the phobia. claustrophobia (Craske et al., 1995). Exposure
However, more studies are needed to firmly treatments yield good results: success percen-
establish the role of this reasoning style in the tages of 90% are no exception. Furthermore,
maintenance of fear. controlled studies show that the efficacy of
Conclusions 471
exposure is maintained at long term follow-up outcome studies designed to compare the
(OÈst, 1996; OÈst et al., 1991b). effectivity of EMDR and exposure in vivo in
The precise mechanism underlying the ben- the treatment of specific phobias indicate that
eficial effects of exposure are a matter of exposure yields better results, especially on the
considerable debate. Some authors have fa- behavioural level of fear (Muris & Merck-
vored an extinction or habituation interpreta- elbach, 1997; Muris, Merckelbach, van Haaf-
tion of exposure effects (Marks, 1987; Watts, ten, & Mayer, 1997).
1979). According to these authors, exposure is
the extinction or habituation of a fear CR to a
CS that is no longer followed by a UCS. Other 6.20.6.3 Benzodiazepines
authors have argued that exposure effects are
There is abundant evidence showing that
linked to cognitive changes rather than response
benzodiazepines have anxiolitic effects (Rickels,
habituation (Foa & Kozak, 1986). They
1978). Furthermore, animal research indicates
emphasize that, during exposure, the patient
that benzodiazepines inhibit conditioned fear
learns that the phobic object is not associated
responses. Consequently, one would predict
with catastrophic events. This will eventually
that benzodiazepines can be useful in the
lead to a correction of the phobic fear. This
treatment of specific phobias. However, studies
formulation is compatible with the S-S view of
designed to evaluate the effect of benzodiaze-
phobic fear (Eysenck, 1987), and also with
pines on phobic avoidance have generally
cognitive theories about phobic fear (Last,
yielded disappointing results (Bernadt, Silver-
1987). There is preliminary evidence that the
stone, & Singleton, 1980; Sartory, MacDonald,
interpretations of exposure that emphasize
& Gray, 1990). Although benzodiazepines
cognitive change are closer to the truth than
might inhibit subjective fear during phobic
extinction/habituation accounts. For example,
confrontation, they do not increase approach
Shafran, Booth, and Rachman (1993) recently
behavior (Sartory et al., 1990). Gray (1987) has
showed that treatment of claustrophobia is
gone one step further and suggested that
successful to the degree that it corrects certain
benzodiazepines might even be harmful in that
key cognitions (e.g., ªI will suffocateº). Simi-
they create state dependency effects: phobics
larly, in their study of one-session exposure
learn to approach the phobic stimulus when
treatment of spider phobia, OÈst et al. (1991b,
drugged, but this learning is not transferred to a
p. 421) remark that ªthe clinical impression
nondrugged state.
from treating these patients is that the most
important factor in the one-session treatment is
making explicit the patientsº catastrophic 6.20.7 CONCLUSIONS
thoughts concerning the phobic situation and
devising the exposure situation in such a way Specific phobias have been well researched.
that these can be tested out.º As a result, we now have a comprehensive
picture of the important elements that constitute
this disorder. To summarize the most important
6.20.6.2 Eye Movement Desensitization and points, specific phobias form a heterogeneous
Reprocessing class of disorders (Himle, Crystal, Curtis, &
Fluent, 1991). The most radical difference is
Eye movement desensitization and reproces- found between animal phobias and claustro-
sing (EMDR) is a relatively new technique that phobia. Compared to animal phobias, claus-
was originally proposed as a treatment method trophobia is characterized by a more elaborated
for post-traumatic stress disorder (Shapiro, set of cognitions, a later age of onset, and a more
1989). During EMDR, patients imaginally pronounced role of conditioning experiences in
expose themselves to a traumatic or aversive the etiology (OÈst, 1987). Accordingly, in claus-
memory, while simultaneously engaging in trophobia, but not in animal phobias, effects of
lateral eye movements that are induced by the exposure treatment are enhanced when the
therapist. The idea is that through eye move- treatment is combined with cognitive interven-
ments, negative memories are emotionally tions (Craske et al., 1995).
processed and assimilated. The therapist-in- Specific fears are common in childhood and
duced eye movements would simulate the there are reasons to believe that cognitive
inhibitory function of rapid eye movement development is closely linked to the content
(REM) sleep. Some authors have claimed that of these fears. In most children these fears
EMDR is not only effective in post traumatic represent transitory phenomena. In a small
stress disorder, but also in specific phobias subgroup of children and adolescents, the
(Marquis, 1991; Shapiro, 1995). However, this specific fears become chronic due to condition-
claim rests entirely on case studies. Controlled ing, modeling, negative information and/or a
heightened disgust sensitivity. It is also possible hormonal and physiological abnormalities in anxiety
that neuroticism may make a general genetic disorders. Psychoneuroendocrinology, 13, 287±307.
Campbell, D., Sanderson, R. E., & Laverty, S. G. (1964).
contribution to the acquisition of such phobias. Characteristics of a conditioned response in human
Once a specific phobia exists, it is maintained by subjects during extinction trials following a single
processes such as cognitive biases and thought traumatic conditioning trial. Journal of Abnormal and
suppression. Consequently, in most cases, the Social Psychology, 68, 627±639.
Cook, M., & Mineka, S. (1989). Observational condition-
natural course of specific phobias is chronic. ing of fear to fear-relevant versus fear-irrelevant stimuli
However, exposure-based treatments are very in rhesus monkeys. Journal of Abnormal Psychology, 98,
effective in reducing specific phobias. 448±459.
In summary, research has yielded a clear Cornelius, R. R., & Averill, J. R. (1983). Sex differences in
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Psychology, 45, 377±383.
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6.21
Social Phobia
HARLAN R. JUSTER
Pine Bush Mental Health, Albany, NY, USA
and
RICHARD G. HEIMBERG
Temple University, Philadelphia, PA, USA

6.21.1.1 Definition of Social Phobia 476
6.21.1.2 Description of Social Phobia 477
6.21.1.2.1 Prevalence 477
6.21.1.2.2 Gender ratio 477
6.21.1.2.3 Age of onset 478
6.21.1.2.4 Chronicity 478
6.21.1.3 Functional Impairment 479
6.21.1.5 Social Phobia and Avoidant Personality Disorder 480
6.21.1.6 Summary 480
6.21.2 UNDERSTANDING THE ETIOLOGY AND MAINTENANCE OF SOCIAL PHOBIA 481
6.21.3 TREATMENT STRATEGIES FOR SOCIAL PHOBIA 481
6.21.3.1 Social Skills Training 481
6.21.3.1.1 Review of empirical studies of SST 482
6.21.3.2 Relaxation Techniques 484
6.21.3.2.1 Review of empirical studies of relaxation techniques 484
6.21.3.3 Exposure-based Techniques 485
6.21.3.3.1 Review of empirical studies of exposure-based techniques 485
6.21.3.4 Cognitive-behavioral Techniques 486
6.21.3.4.1 Review of empirical studies of cognitive-behavioral techniques 486
6.21.3.5 Psychodynamic Formulations 492
6.21.4 PREDICTORS OF OUTCOME 492
6.21.5 SUMMARY AND FUTURE DIRECTIONS 493
6.21.1 INTRODUCTION viewed for a job, given a presentation, or gone on

a first date with someone to whom they were
Social anxiety is a common experience, and attracted has experienced the concerns asso-
most individuals can recall some event in their ciated with coming under the scrutiny of others.
lives when they experienced concern about being When anxiety in these situations becomes severe
evaluated by others. Anyone who has inter- and interferes with the adaptive functioning of
475
476 Social Phobia
the individual, the diagnosis of social phobia detail. One of the first descriptions of social
may be assigned. The following are examples: phobia was provided by Marks and Gelder
(1966). Social phobia was described as the
Mr S., a man in his mid-20s, reports being anxious experience of anxiety in situations where an
when meeting new people. Nevertheless, he man- individual might perform some task under the
aged to graduate from high school and secure a job scrutiny of others. These ªperformanceº tasks
in sales which appears to cause him little difficulty. included public speaking, writing or eating in
He has a small circle of friends from his adolescent
front of others, and using public restrooms
years but is very uncomfortable when meeting
anyone for the first time. He actively avoids while others were present. Fears expressed by
socializing in situations which may involve ªtoo the individual with social phobia in these
many new people.º He managed to meet and situations focused primarily on one of two
marry a woman two years ago, but she is frustrated concerns: that the individual would do or say
by his reluctance to meet new people. Mr. S. copes, something embarrassing or that symptoms of
in part, by smoking marijuana with his small circle anxiety would be visible to others. When these
of friends. He has also recently begun to use performance tasks could adequately be per-
marijuana on his own outside of social situations. formed in the absence of others, social phobia
He is not happy about this behavior but reports was said to be present.
that it is the only thing that calms him down after a
This early conceptualization provided the
long day of interacting with others.
Ms. B. is a single woman in her late 30s who framework for the diagnostic criteria for social
currently works as a reference librarian. She has phobia in the third edition of the Diagnostic and
dated only occasionally, and her social life is a statistical manual of mental disorders (DSM-III;
source of much distress. She dreams of having a American Psychiatric Association [APA],
family but doubts her ability to achieve this dream. 1980). Social phobia was defined by the
She has become more depressed, beginning to feel experience of fear in and a compelling desire
hopeless about her future prospects. To complicate to avoid one of several specific situations.
her situation, the library is beginning a new Notably absent from this early view was anxiety
outreach program and she will be expected to associated with interpersonal interaction. Inter-
speak with students in the local schools, something
personal anxiety was not considered to be part
she dreads. She seeks treatment now for what she
views as her last opportunity to turn her life of the social phobia ªpicture,º and individuals
around. with this type of anxiety were instead given the
Axis II diagnosis of avoidant personality
As these examples illustrate, social phobia disorder (APD). This, however, would change
can be a debilitating disorder, causing consider- with the next revision of the diagnostic criteria.
able impairment in occupational, educational, As more was learned about individuals with
and social functioning. Individuals with social social phobia, it became apparent that many
phobia often have difficulty making friends, individuals who experienced anxiety in perfor-
finding partners, and remaining socially con- mance situations also feared interacting with
nected to others. They may make important others. Thus, when the revision of DSM-III
career decisions which accommodate their so- (DSM-III-R; APA, 1987) was published, the
cial anxiety even if these decisions make it scope of the diagnosis was broadened to include
unlikely that they will achieve their personal social interactional fears. Several additional
goals. For example, they may opt for college findings and concerns supported this decision,
courses which require no public speaking, including research documenting that most
choose vocations because they present few patients with social phobia reported multiple
demands for social interaction, or simply opt fears (Turner, Beidel, Dancu, & Keys, 1986), the
out of employment altogether. Some may settle observation that clinicians often applied the
for an easily available romantic partner regard- diagnosis of social phobia to individuals with
less of level of attraction. Understanding social multiple social fears (Spitzer & Williams, 1985),
phobia and its concomitants is a crucial task, and the concern that classifying interpersonal
especially since social phobia may be much anxiety as an Axis II disorder might discourage
more common than previously believed. The research into its treatment (Liebowitz, Gorman,
recognition of social phobia and knowledge of Fyer, & Klein, 1985) (see Heimberg, 1996, for a
effective treatment options are important con- more detailed discussion of these issues).
siderations for the clinical psychologist. With the broadening of the diagnostic
criteria, a generalized subtype was added to
6.21.1.1 Definition of Social Phobia describe those individuals with social phobia
who feared most social interactions. Avoidance,
Our understanding of social phobia has while common, was not essential for the
evolved considerably since the 1960s, and it is diagnosis in recognition of the fact that some
instructive to examine that evolution in some individuals with social phobia often endure the
Introduction 477
personal distress associated with feared situa- reported in the ECA studies may arise from
tions. Social phobia, previously viewed as rare multiple sources. For example, there were a
and rarely debilitating, was described as much number of methodological differences between
more common and associated with potentially the ECA and NCS studies that might account
severe impairment. for differences in reported prevalence. Specifi-
The definition of social phobia remains cally, in the ECA studies, interviewers inquired
essentially unchanged in the DSM-IV (APA, about the individual's anxiety in only three
1994). Our knowledge of social phobia has situations (eating in front of others, public
matured as further research has been conducted speaking, and speaking to strangers or meeting
and our knowledge base has expanded. In fact, new people). The NCS interview inquired about
two important volumes have been published fear in these three situations, but also queried
surveying the current ªstate of our knowledgeº three additional situations: using toilets away
regarding this disorder (Heimberg, Liebowitz, from home, writing while being watched, and
Hope, & Schneier, 1995; Stein, 1995). What was sounding foolish in front of others. Since both
once described as a ªneglected anxiety disorderº studies required endorsement of fear and
(Liebowitz et al., 1985) is now much better interference in only one situation in order to
understood. receive a diagnosis of social phobia, the odds of
a positive diagnosis were higher in the NCS than
the ECA. Furthermore, the probe regarding
6.21.1.2 Description of Social Phobia ªsounding foolish in front of othersº reflects the
broadening of the social phobia diagnosis to
6.21.1.2.1 Prevalence
include a greater focus on anxiety in social
In the National Institute of Mental Health interaction, not reflected in DSM-III. Clearly,
Epidemiological Catchment Area (ECA) stu- the increase in the number of situational probes,
dies, the six-month prevalence for DSM-III as well as the broadening of the scope of inquiry
social phobia was reported to be 1.5±2.6% for to include more social interaction situations,
women and 0.9±1.7% for men (Myers et al., may identify more individuals with social
1984). The lifetime prevalence of social phobia phobia.
at four ECA sites was 2.4% for men and women Methodological differences and criterion
combined (Schneier, Johnson, Hornig, Liebow- changes may not be the only reasons that
itz, & Weissman, 1992). More recently, the prevalence rates differ between studies. Magee,
National Comorbidity Survey (NCS; Kessler Eaton, Wittchen, McGonagle, and Kessler
et al., 1994) was conducted in the United States (1996) report that the prevalence of social
with a national probability sample of more than phobia may, in fact, be increasing. Analysis
8000 participants between the ages of 15 and 54 of the NCS data demonstrated the existence of
years. The 12-month prevalence of DSM-III-R cohort effects, such that younger cohorts of
social phobia was reported to be 7.9% (6.6% for subjects (ages 15±24) showed higher prevalence
men and 9.1% for women), and the lifetime rates than older cohorts (ages 25 and up). These
prevalence of social phobia was reported to be findings were most pronounced for agorapho-
13.3% (11.1% for men and 15.5% for women). bia, but were also noted for simple and social
The high lifetime prevalence of social phobia phobia. This trend towards increasing preva-
makes it the third most common mental disorder lence rates in younger cohorts has also been
examined in the NCS after major depression noted for major depression in several studies
(17.1%) and alcohol dependence (14.1%). around the world (Cross-National Collabora-
Similar prevalence rates for DSM-III-R tive Group, 1992; Klerman & Weissman, 1989;
social phobia were reported in two other studies Wickramaratne, Weissman, Leaf, & Holford,
conducted outside the United States. A study of 1989).
470 Swiss adults revealed a lifetime prevalence
rate of 16% for DSM-III-R social phobia,
6.21.1.2.2 Gender ratio
similar to the rate reported in the NCS (Wacker,
Mullejans, Klein, & Battegay, 1992). In Win- Epidemiological data suggest that more
nepeg, Manitoba, a telephone survey examined women than men suffer from social phobia.
the nature of social anxiety in the community as For example, across four ECA sites, approxi-
well as the prevalence of DSM-III-R social mately 70% of individuals with social phobia
phobia (Stein, Walker, & Forde, 1994). Of 526 were women (Schneier et al., 1992). In the
respondents, 7.1% met criteria for the diagnosis NCS, women with social phobia outnumbered
of social phobia at the time of assessment, men with social phobia about 1.4 to 1. This
similar to the 12-month NCS prevalence rate. gender difference in prevalence is not apparent
The higher prevalence rates reported in these in treatment settings, however, where men and
studies compared with the much lower rates women with social phobia present in approxi-
478 Social Phobia
mately equal numbers (Mannuzza, Fyer, of research converge to support the perspective
Liebowitz, & Klein, 1990). This may be related that social phobia is a chronic disorder. In one
to different sociocultural expectations for men such study, Reich, Goldenberg, Vasile, Gois-
and women. For example, women perceived as man, and Keller (1994) followed 140 subjects
shy may fit stereotypical images of femininity with social phobia for over one year. Seventy-
and experience less demand to overcome their four subjects were diagnosed with generalized
social anxiety. Conversely, men may experi- social phobia and the remainder (66) with
ence more pressure to alter their social anxiety discrete social phobia (fear of one or more
and avoidance which are less consistent with specific performance situations). After 65
stereotypical conceptions of masculinity. weeks, only 11% of the sample achieved full
The study of gender differences was extended remission despite the fact that 88% received
to examine whether there were differences some form of psychotherapy or pharmacother-
between men and women with social phobia apy during this period. Importantly, there were
in the severity of their anxiety or in the nature of no differences in chronicity between subjects
the situations in which they reported clinically with generalized vs. discrete social phobia,
significant anxiety (Turk, Heimberg et al., in suggesting a similar course for these two
press). Women exhibited more severe social variants of the disorder.
fears on several measures. They also reported Studies on shyness, a construct closely related
significantly greater fear than men while talking to social phobia, may shed additional light on
to authority, acting/performing/giving a talk in the issue of chronicity. Shyness, which is not a
front of an audience, working while being diagnostic entity, has never been defined
observed, entering a room when others are consistently by researchers. However, every
already seated, being the center of attention, definition of shyness has included the concept
speaking up at a meeting, expressing disagree- of anxiety regarding social interaction, suggest-
ment or disapproval to people they don't know ing that shyness and social phobia are closely
very well, giving a report to a group, and giving allied (Turner, Beidel, & Townsley, 1990).
a party. Men reported significantly more fear Research reviewed by Turner et al. (1990)
than women regarding urinating in public examining social phobia and shyness further
bathrooms and returning goods to a store. suggests that the two conditions, while not
Not surprisingly, more men than women with identical, broadly overlap on behavioral, cog-
social phobia reported full-time employment. nitive, and physiological indices. Rapee (1995)
has suggested that the two conditions differ
more quantitatively than qualitatively, espe-
6.21.1.2.3 Age of onset cially on indices of impairment and avoidance,
with social phobia being the more extreme
Hazen and Stein (1995) reviewed 15 epide-
condition. Thus, research on shyness in children
miological and clinical studies and found the
and its influence on later levels of functioning
mean age of onset of social phobia to range
may reveal something about the chronicity of
between 13 and 20 years. However, age of onset
social anxiety. One prospective study found that
may differ by subtype of social phobia. For
boys identified as shy were likely to marry and
example, Holt, Heimberg, and Hope (1992)
achieve occupational stability later in life than
found that the age of onset for a sample of
nonshy boys (Caspi, Elder, & Bem, 1988).
subjects with generalized social phobia was
Childhood shyness also influenced girl's later
about 13 years of age, whereas the age of onset
development. Compared with nonshy girls, shy
for subjects with nongeneralized social phobia
girls were more likely to become housewives or
was 22.6 years. This finding was later replicated
to remain at home after childbirth. Thus, early
by Brown, Heimberg, and Juster (1995). To
experiences with social anxiety, specifically
further complicate this picture, data from the
shyness in children, were predictive of adult
NIMH ECA studies reported by Schneier et al.
behavior which could be broadly construed as
(1992) suggest that the distribution of age of
the demonstration of social impairment or
onset of social phobia may be bimodal with one
avoidance.
peak at 13 years of age and an earlier peak at
Finally, ªbehavioral inhibition,º or the
under five years of age. This pattern suggests
tendency to withdraw in the face of novel
that there may be more than one pathway to the
people, places, and things, has been identified in
development of social phobia.
very young children and may persist for years
(Kagan, Reznick, & Snidman, 1988). Kagan
et al. (1988) report that behavioral inhibition
6.21.1.2.4 Chronicity
occurs in approximately 10±15% of children. A
Although no true ªnatural historyº studies of majority of children classified as behaviorally
social phobia have been conducted, several lines inhibited prior to age three remained inhibited
Introduction 479
for at least 10 years (Rosenbaum, Biederman, 6.21.1.4 Comorbidity

Pollock, & Hirshfeld, 1994). Furthermore,
behaviorally inhibited children were more Comorbidity is high among individuals with
introverted and more physiologically reactive social phobia. Schneier et al. (1992) reported
to stress than uninhibited children. More that among ECA subjects with DSM-III social
revealing, however, is that the presence of phobia, 69% had at least one comorbid disorder
behavioral inhibition in children was associated (excluding dysthymia and simple phobia).
with a greater occurrence of childhood anxiety When comparing rates of comorbidity between
disorders (Biederman et al., 1990) and a higher subjects with social phobia and subjects with
likelihood of anxiety disorders, especially social other disorders but not social phobia and
phobia, in the parents of these children subjects with no disorders (the latter two groups
(Rosenbaum et al., 1991). being combined into a no social phobia group),
elevated rates of comorbidity in the social
phobia group were found for all disorders
studied. For example, simple phobia and
6.21.1.3 Functional Impairment agoraphobia were the most commonly occur-
ring comorbid diagnoses in the social phobia
Social phobia is often associated with group with lifetime rates of 59% and 45%,
significant impairment in occupational and respectively, compared to rates of 13.2% and
educational attainment as well as social 6.1% in the no social phobia group. Other
functioning (Amies, Gelder, & Shaw, 1983; disorders with elevated comorbidity rates were
Liebowitz et al., 1985; Magee et al., 1996; panic disorder (4.7% vs. 1.3%), major depres-
Schneier et al., 1992, 1994; Turner et al., 1986). sion (16.6% vs. 4.0%), obsessive-compulsive
For example, Schneier et al. (1992) re-evaluated disorder (11.1% vs. 2.5%), somatization dis-
the data of subjects with social phobia from order (1.9% vs. 0.2%), dysthymia (12.5% vs.
four of the five ECA study sites. Subjects with 3.1%), and bipolar disorder (4.7% vs. 1.1).
social phobia were less educated, of lower When a comorbid disorder was diagnosed,
socioeconomic status, and less likely to be social phobia was the temporally primary
married when compared to subjects with other disorder 77% of the time.
disorders (but not social phobia) and to In the NCS study, 81% of persons with DSM-
nondisordered subjects. Another study found III-R social phobia had at least one other
that subjects with social phobia were less likely disorder (Magee et al., 1996). Again, social
to be married than subjects with agoraphobia, phobia was highly comorbid with simple phobia
although they also were likely to be younger at (37.6%), agoraphobia (23.3%), and major
the time of referral than the agoraphobic depression (37.2%). Substantial rates of co-
subjects (Amies et al., 1983). Both of these morbidity were evident for any affective
studies examined social phobics diagnosed disorder (41.4%) and any anxiety disorder
according to DSM-III. However, similar im- (56.9%). Again, social phobia was the tempo-
pairment is observed whether DSM-III or rally primary disorder in the majority of cases.
DSM-III-R criteria for social phobia are Substance-related disorders also commonly
employed. Magee et al. (1996) reported that co-occur with social phobia. In the ECA studies,
DSM-III-R social phobia was associated with 18.8% of social phobics were comorbid for
less educational attainment, lower income, alcohol abuse and 13% for drug abuse (Schneier
reduced likelihood of being married or em- et al., 1992). In a subset of subjects from the
ployed, and a greater likelihood of living with ECA studies, social phobia was highly comor-
one's parents. Schneier et al. (1994) compared bid with alcohol-related disorders (Himle &
the self-rated impairment of 32 DSM-III-R Hill, 1991). Nearly 28% of social phobics also
social phobic subjects who were not currently had an alcohol-related disorder compared with
depressed and a group of normal control 13±24% for nonsocial phobics. In the NCS,
subjects. The social phobic subjects reported these figures are even higher. Alcohol abuse and
significantly higher levels of impairment in alcohol dependence were diagnosed in over
every category of social functioning (family 30% of DSM-III-R social phobics, whereas
relations, romantic relationships, and social drug abuse and drug dependence were diag-
network) and occupational functioning (educa- nosed in over 20% of social phobics (Magee
tion and employment), as well as alcohol and et al., 1996). Nearly 40% of DSM-III-R social
drug use, mood regulation, and activities of phobics had a comorbid substance-related
daily living. Finally, individuals with social disorder.
phobia report less satisfaction with their lives While alcohol-use disorders are more com-
than persons without social phobia (Safren, mon in social phobics than in the community at
Heimberg, Brown, & Holle, 1997). large, social phobia is also more common
480 Social Phobia
among alcoholics than in the community. combination of generalized social phobia and
Estimates of the prevalence of social phobia APD probably represents a more severe man-
in subjects diagnosed with alcohol-related ifestation of social phobia.
disorders run as high as 40% (Ross, Glaser, Differential response to treatment by general-
& Germanson, 1988; Smail, Stockwell, Canter, ized social phobics with and without APD might
& Hodgson, 1984). Kushner, Sher, and Beitman highlight distinctions between these two dis-
(1990) reported that social phobia was nine orders, and the effects of treatment designed
times more common among patients with specifically for social phobia on the diagnosis of
alcohol disorders than in a community sample. APD might further clarify this relationship.
Data provided by Magee et al. (1996) and Brown et al. (1995) examined these issues in the
Schneier et al. (1992) are remarkably consistent context of cognitive-behavioral group treatment
despite the differences between the ECA and for social phobia. On the majority of outcome
NCS studies. Comorbidity of social phobia with measures, there were no post-treatment differ-
other anxiety disorders, affective disorders, and ences between generalized social phobics with or
substance-related disorders is common. In the without APD. On the remaining measures, social
majority of cases, social phobia is the tempo- phobics with APD remained more severely
rally primary condition, its onset preceding the impaired. Importantly, 47% (8 of 17) of the
onset of comorbid conditions. patients diagnosed with APD prior to treatment
no longer met APD criteria following treatment.
Hope, Herbert, and White (1995b) reported that
6.21.1.5 Social Phobia and Avoidant Personality APD did not differentially predict outcome of
Disorder cognitive-behavioral group treatment for social
phobia. However, in this study, subtype of social
Early on, APD and social phobia were phobia and APD diagnosis were not considered
defined as relatively distinct diagnostic entities. simultaneously. Feske, Perry, Chambless, Re-
Social phobia referred to fear in circumscribed nneberg, and Goldstein (1996) treated general-
performance situations, whereas APD referred ized social phobics with and without APD with a
to more broad-based fear of social interaction. combination of behavioral techniques (expo-
With the publication of DSM-III-R, changes in sure, relaxation, social skills training, and
the diagnostic criteria were introduced which systematic desensitization). Although both
blurred the distinction between these two groups significantly improved, generalized so-
disorders. For example, the generalized subtype cial phobics with APD began and ended
of social phobia, added in DSM-III-R, referred treatment more impaired than social phobics
to fear in most social situations, a profile which without APD. This pattern of results was also
previously would have excluded a diagnosis of evident at three-month follow-up.
social phobia. Also, the criteria for APD were These results lend further support to Widi-
modified such that there was now a greater ger's (1992) conclusion noted above, that
emphasis on fear of negative evaluation and generalized social phobia and APD differ more
social discomfort, a central feature of social quantitatively than qualitatively. In his review,
phobia. Whereas in DSM-III, five of five criteria Heimberg (1996) takes this argument a step
had to be met for the diagnosis of APD, only further by questioning the appropriateness of
four of seven were required in DSM-III-R, separating these two diagnoses on to Axis I and
making it easier for the diagnosis to be awarded. Axis II. Most importantly for the clinical
This situation remains essentially unchanged in psychologist who may be treating generalized
DSM-IV (see Heimberg, 1996, for a fuller social phobics with and without APD is that
discussion of the issues related to generalized response to treatment for these subjects appears
social phobia and APD). to be similar.
A number of articles have addressed the
degree of overlap between generalized social
phobia with and without APD (Brown et al., 6.21.1.6 Summary
1995; Herbert, Hope, & Bellack, 1992; Holt
et al., 1992; Schneier, Spitzer, Gibbon, Fyer, & Social phobia, a chronic anxiety disorder, is
Liebowitz, 1991; Tran & Chambless, 1995; highly prevalent in both men and women, and is
Turner, Beidel, & Townsley, 1992). Despite associated with significant functional impair-
differences in sampling procedures, subtype ment and personal distress. Although the
definition, and diagnostic instruments, the average age of onset is in the early teens, some
degree of overlap was high, ranging from 25 individuals appear to suffer with the disorder
to 89% in these six studies. Widiger (1992) from a much earlier age. Comorbidity with
concluded that generalized social phobia and other conditions is the rule although social
APD were more alike than not and that the phobia usually begins first. We turn our
Treatment Strategies for Social Phobia 481
attention now to possible explanations of the enters a social situation. As noted above,
development of social phobia. individuals with social phobia make assump-
tions about the nature of social situations which
6.21.2 UNDERSTANDING THE provide the foundation upon which the experi-
ETIOLOGY AND MAINTENANCE ence of social anxiety is built. These assump-
OF SOCIAL PHOBIA tions compel them to monitor their
performance and others' evaluation of them
As knowledge of social phobia has increased, at all times. Thus, when individuals with social
researchers have developed models of the causes phobia enter social situations, they form mental
and maintaining factors of social anxiety and representations of themselves as they believe
social phobia (e.g., Clark & Wells, 1995; they appear to their audience. Simultaneously,
Heimberg, Juster, Hope, & Mattia, 1995; Leary they compare their own perception of their
& Kowalski, 1995; Rapee & Heimberg, 1997). performance in this situation with the standard
An integrative model of the etiology of social of performance they believe to be held for them
phobia was put forth by Heimberg et al. (1995). by their audience. While attention is given to
Drawing from a broad range of empirical and this internal representation, individuals also
theoretical literature, they argue for a diathesis- attend to the environment, searching for
stress conceptualization in which the principal potential threat as well as internal cues (e.g.,
etiological mechanism is an interaction between tachycardia) which may suggest inadequate
biological predisposition (Fyer, Mannuzza, performance. Negative signs from without or
Chapman, Liebowitz, & Klein, 1993) and within may then serve as indicators that
environmental factors. Results from twin negative evaluation is likely, and anxiety ensues.
studies and family studies combine to support The entire experience has further negative
the view that a tendency to interpret situations impact as it may serve to strengthen maladap-
as potentially threatening may be partially tive beliefs and lower expectations for success in
inherited. This general tendency to become similar future situations.
anxious and interpret situations as potentially
threatening may represent a general response
pattern that becomes more specifically focused 6.21.3 TREATMENT STRATEGIES FOR
on social stimuli as a result of environmental SOCIAL PHOBIA
factors (Bruch & Heimberg, 1994; Bruch,
Several comprehensive reviews of treatment
Heimberg, Berger, & Collins, 1989). Such
strategies for social phobia have been written
environmental factors may include a parent's
(Heimberg, 1989; Heimberg & Barlow, 1988;
anxiety about social interaction which is
Heimberg & Juster, 1995; Hope, Holt, &
communicated to the child directly or indirectly.
Heimberg, 1993; Juster, Heimberg, & Holt,
Parents may also emphasize the opinions of
1996) including one which focused on long-term
others as excessively important, withhold
outcome (Juster & Heimberg, 1995). The paper
approval for anything less than perfect perfor-
by Heimberg (1989) reviewed just 17 studies. In
mance, and/or isolate their child from social
contrast, the current chapter reviews 37 studies,
interaction. Early negative peer group interac-
five of which focus specifically on long-term
tions may further sensitize individuals to the
outcome. The field of social phobia treatment is
ªpotential dangerº of social interaction.
rapidly growing in size and sophistication.
Repeated exposure to early sensitizing ex-
periences may contribute to the development of
cognitive structures (i.e., schemata) which 6.21.3.1 Social Skills Training
define other people as inherently critical and
social situations as inherently dangerous and Early attempts to treat individuals with social
threatening to one's self-esteem. Furthermore, phobia were based on the premise that the
the individual may come to believe that only person's social anxiety was a result of a deficit in
perfect performance would allow him/her to social skills, that is, a lack of knowledge of how
avoid the danger of criticism and negative to perform or capacity to perform in social
evaluation by others but that performance up to situations. Although a logical possibility, there
that standard is highly unlikely (Juster, Heim- is little empirical support for this notion (Juster
berg, Frost, et al., 1996). These cognitive & Heimberg, 1995). It is clear that individuals
structures are postulated to be an underlying, with social phobia exhibit deficits in their social
maintaining mechanism for the experience of performance; however, this performance deficit
anxiety in social situations. has never been linked to a singular cause (i.e.,
Rapee and Heimberg (1997) have delineated a social skills deficit). Possible causes of perfor-
theoretical model of the experience of anxiety mance deficits include inhibition of behavior by
when a person with social phobia anticipates or anxiety or maladaptive beliefs, avoidance of
482 Social Phobia
certain situations due to anticipatory anxiety, or of drop-outs, although it appears that SST-
a social skills deficit, among others. Our clinical treated subjects maintained their gains. Neither
experience suggests that the first two are more treatment produced significant improvement in
likely explanations for the performance deficits social skills or reduction in anxiety. Further-
seen in social phobic individuals. In clinical more, with the exception of those differences
settings, social phobics repeatedly perform noted above, improvements found in the treated
feared activities as part of exposure exercises subjects were generally not reflective of im-
during treatment or as part of behavioral provements over and above those achieved by
assessment tasks, and their performance during the wait-list group.
these tasks is typically ªwithin normal limits.º Trower, Yardley, Bryant, and Shaw (1978)
Despite usually adequate performance, the also compared SST and SD. They specifically
individual's self-report is almost always marked identified subjects as having either a social-skills
by negative self-bias (Rapee & Lim, 1992). deficit or excessive anxiety as their principal
Although social phobics may report that they difficulty. Half of the identified subjects in each
do not know what to say or how to act in social group were then assigned randomly to one of
situations, their actual behavior often suggests the two treatments, so that half of the subjects
otherwise. were assigned to treatments matching their
Despite the lack of support for social skills deficit while the other half were in a mismatched
deficits as an overall explanatory mechanism for condition. This treatment-matching appears
social phobia, it clearly remains a possibility for frequently in the social phobia treatment
some individuals. Whether or not an individual literature.
lacks social skills, social skills training (SST) Patients in all treatment conditions evidenced
may provide some benefit by providing ex- reduction in the severity of their phobias, social
posure to anxiety-evoking stimuli, providing inadequacy, and general anxiety following
information about one's ability to perform in treatment regardless of the specific type of
social situations, etc. Social skills training is an deficit they exhibited. There was also some
amalgam of behavioral techniques designed to specific benefit for skill-deficit subjects treated
give patients experience with and exposure to with SST. For example, skill-deficit subjects
various types of behavioral practice. Techniques who received SST engaged in more social
such as therapist modeling, behavioral rehear- activities and experienced less difficulty in social
sal, corrective feedback, social reinforcement, situations compared with skills-deficit patients
and homework assignments may all be compo- treated with SD. No such treatment-matching
nents of social skills training interventions. advantage occurred for the primarily anxious
subjects who benefited equally from both
treatments.
6.21.3.1.1 Review of empirical studies of SST
Shaw (1979) extended the results of Trower
We now turn to the review of treatment et al. (1978) by treating 10 additional anxious
strategies designed specifically for the remedia- subjects with imaginal flooding (repeated pre-
tion of social skills deficits. Marzillier, Lambert, sentation of highly anxiety-provoking scenes to
and Kellet (1976) compared SST with systema- imagination). These additional subjects showed
tic desensitization (SD; the combination of reductions in phobic severity, social inade-
progressive muscle relaxation and the presenta- quacy, and general anxiety similar to those
tion of scenes of gradually increasing anxiety- attained by subjects treated with SST and SD.
evoking potential to imagination) in the treat- Although patients treated with SST, SD, and
ment of 20 subjects who, by description, met imaginal flooding were significantly improved,
criteria for generalized social phobia. This study the lack of a control condition in Trower et al.
predated the inclusion of social phobia in the (1978) and Shaw (1979) is problematic. This is
official diagnostic nomenclature, but it appears especially the case given the results of the study
that subjects would have met criteria for the by Marzillier et al. (1976) in which treated
current conceptualization of the disorder. subjects were only marginally improved over a
Subjects were assigned randomly to one of the wait-list control condition. The lack of adequate
two treatment conditions (or a wait-list control) experimental control plagues several of the
and received 15 weekly, 45-minute sessions of studies reviewed in this paper.
SST or SD. OÈst, Jerremalm, and Johansson (1981) also
Subjects treated with SST increased their employed a treatment-matching design. Thirty-
range of social activities, while subjects in both two patients with social phobia were classified
treatment conditions increased social contacts as either ªbehavioral reactorsº or ªphysiologi-
in comparison to subjects on the waiting-list. cal reactorsº based upon their responses during
Between-groups analysis during a six-month a role-played social interaction. Physiological
follow-up was precluded due to a high number reactors evidenced greater cardiac reactivity
during the interaction, whereas behavioral social phobia. Wlazlo, Schroeder-Hartwig,

reactors evidenced greater overt signs of anxiety Hand, Kaiser, and MuÈnchau (1990) compared
during the conversation. Half the subjects in an individually-tailored but group-adminis-
each group were then assigned randomly to tered SST program (Liberman, King, De Risi,
either SST or applied relaxation (AR). AR & McCann, 1975) with individual- and group-
combines multiple relaxation procedures (see administered exposure. Seventy-eight patients
below) and was hypothesized to be a better were judged retrospectively to have either a
treatment match for the physiological respon- ªprimary social skills deficitº or a ªprimary
ders. SST was presumed to be the best treatment social phobia.º Subjects were assigned to
match for patients with disrupted behavioral treatments based only upon the time they
responses. applied for treatment. Thus, there was no
There was some limited support for treatment random assignment of subjects to treatment
matching in this study. Behavioral reactors condition, and there was no systematic match-
treated with SST (matched condition) increased ing of subject type to treatment type.
social activity and social contacts, evidenced Both groups of subjects receiving SST re-
greater improvement on self-report measures of ported reduced social anxiety, avoidance, and
social fear, social difficulty, and avoidance of interference of their symptoms with daily life
social situations, and reported lower subjective activities. They also evidenced reductions in
anxiety during a behavioral test when compared depression and obsessive rumination. Similar
with behavioral reactors treated with AR gains were made by subjects treated in the
(mismatched condition). Physiological reactors exposure conditions, and there were few differ-
participated in more social activities, made ences at either the post-treatment or three-
more social contacts, and evidenced fewer signs month follow-up assessment. Although patients
of anxiety during the behavioral test when treated with SST made significant gains, it is
treated with AR (matched condition) than when difficult to determine how much of these gains
treated with SST (mismatched condition). Most should be attributed to SST or the remediation
analyses showed no differences between the of social skills deficits since all patients were
matched and mismatched groups. given specific instructions for exposure as part
Mersch, Emmelkamp, BoÈgels, and van der of the homework component of all treatments.
Sleen (1989) used a similar treatment-matching
approach to identify behavioral reactors, as
(i) Addition of other treatment components
defined in OÈst et al. (1981), and ªcognitive
reactors.º This latter group comprised subjects Two studies have examined the efficacy of
with social phobia scoring relatively lower on a adding other treatment components to SST for
measure of rational thinking. SST and rational- the treatment of social phobia. Stravynski,
emotive therapy (RET; Ellis, 1962) were Marks, and Yule (1992) examined the addition
administered in group format to half of the of cognitive modification procedures to SST in
subjects in each group. RET is a complex the treatment of 22 subjects meeting DSM-III
cognitive-behavioral therapy that involves the criteria for social phobia. Subjects received 12
analysis and disputation of clients' irrational weekly 1.5-hour individual or group sessions
beliefs (Ellis, 1962). Social anxiety was reduced (assignment to individual or group modes of
significantly in every condition, and there were treatment was not random) following a control
some findings which ran counter to the waiting period in which all subjects received
treatment-matching hypothesis. For example, only assessments. Patients in both conditions
patients receiving SST were rated as being less (SST with or without cognitive modification)
anxious and more skillful on a behavioral test reported increases in degree of social interaction
but also reported more positive self-statements and reductions in depression and irrational
at post-treatment. Subjects receiving RET rated beliefs regarding social situations following
themselves as more skillful and less anxious at treatment. Similar results were reported at
post-treatment and six-week follow-up. There post-treatment assessment in both individual
were virtually no differences between subjects in and group treatment conditions. At six-month
the matched and mismatched conditions. Four- follow-up, gains were maintained with essen-
teen months after treatment ended, SST and tially no difference between subjects in the two
RET treated subjects maintained their within- treatment conditions. Cognitive procedures did
group gains (Mersch, Emmelkamp, & Lips, not produce any benefit over and above SST
1991). There were no differences between alone. This issue will be discussed further in
treatment conditions or between subjects trea- Section 6.21.3.4.1(iii).
ted in the matched vs. mismatched conditions. Falloon, Lloyd, and Harpin (1981) examined
One study compared SST with exposure to whether the addition of propanolol, a beta-
feared social situations for the treatment of blocker, would enhance the effects of SST for 16
484 Social Phobia
subjects meeting DSM-III criteria for social Turner, Beidel, and Cooley-Quille (1995)
phobia. Treatment which began after a four- contacted patients for follow-up assessment
week waiting period, was targeted at two two years after they completed SET. Eight of the
problematic situations for each subject, with original 13 patients completed a self-report
each problem the focus of one-half of the total battery while the remaining five completed a
treatment effort. SST began with a six-hour telephone interview. These patients maintained
marathon session in which each subject met with their gains or made some additional gains 21±24
another subject and a lay therapist focusing on months after the conclusion of treatment.
the first problem situation. This was followed by Although these studies produced promising
two weeks of in vivo practice with the aid of the results, they are clearly preliminary and require
therapist. The focus then shifted to the second follow-up evaluation in controlled treatment
problem situation and the procedures were trials. Furthermore, they tell us little about the
repeated. efficacy or mechanism of SST for social phobia.
No changes occurred during the pretreatment
waiting period. Analyses of within-group
6.21.3.2 Relaxation Techniques
changes showed reductions in social anxiety,
decreased difficulty in targeted situations, and The use of relaxation techniques for social
increases in positive self-image. A six-month phobia is based on the straightforward notion
follow-up of 81% of the subjects indicated that that they should provide the person with a
gains were maintained. There were no between- means of coping with the physiological mani-
groups differences, however, indicating that festations of anxiety. Several studies have
propanolol did not enhance the efficacy of SST. examined the effectiveness of relaxation strate-
gies in the treatment of social phobia. Most
(ii) Recent advances commonly, studies of this sort employ one of
only a few strategies. In this section, we review
Although interest in SST had declined in studies that have employed either progressive
recent years, it has received renewed interest as muscular relaxation (Jacobson, 1938), systema-
part of multicomponent treatment packages for tic desensitization (Wolpe, 1958), or applied
the treatment of more severely disturbed relaxation (OÈst, 1987).
individuals. Two studies present preliminary
data on the efficacy of treatments which
combine several treatment components and 6.21.3.2.1 Review of empirical studies of
which prominently feature social skills training. relaxation techniques
Feske et al. (1996) used a combination of group Three studies already reviewed (Marzillier
exposure, relaxation training, systematic desen- et al., 1976; Shaw, 1979; Trower et al., 1978)
sitization, and SST in the treatment of general- examined SD in comparison with SST and
ized social phobics with and without avoidant imaginal flooding. As noted, those studies
personality disorder. Both groups of patients found within-group improvements for SD but
improved from pretest to post-test and achieved few group differences between SD and the other
further gains by three-month follow-up. Differ- treatments. Furthermore, just one study in-
ences between patients with and without APD cluded a control condition, and that study
have been previously described. showed little benefit for SD above and beyond
Social effectiveness therapy (SET) combines the wait-list control group (Marzillier et al.).
education, social skills training, imaginal ex- Two other studies compared progressive
posure, and therapist-directed exposure (Turn- muscular relaxation to exposure techniques
er, Beidel, Cooley, Woody, & Messer, 1994). (Al-Kubaisy et al., 1992; AlstroÈm, Nordlund,
Turner et al. (1994) employed a broad set of Persson, HaÊrding, & Ljungqvist, 1984). In both
assessments including self-report measures, a studies (reviewed in more detail in the section on
standardized behavioral test, and clinician exposure techniques), relaxation fared poorly
ratings as well as a composite index of outcome when compared with exposure.
(Turner, Beidel, Long, Turner, & Townsley,
1993) in an uncontrolled study of 17 patients
(i) Applied relaxation
meeting criteria for generalized social phobia. A
combination of individual and group-treatment OÈst and colleagues have had more success
sessions were administered for 29 sessions with alternative strategies employing relaxation
conducted over 16 weeks. At post-treatment, techniques by linking relaxation more closely to
84% of the 13 patients who completed treat- actual social situations. Applied relaxation
ment (59% of the full sample) were classified as (AR) involves a series of techniques in which
having achieved either moderate or high end- subjects (i) increase awareness of the earliest
state functioning. signs of anxiety and (ii) apply a series of
relaxation techniques during anxiety-provoking anxiety in the seven patients who completed
situations (OÈst, 1987). These techniques begin treatment. Al-Kubaisy et al. (1992) compared
with standard progressive muscular relaxation self-directed in vivo exposure with and without
strategies but then aim to decrease the time therapist assistance to relaxation strategies in
required to achieve a relaxed state. With the treatment of 28 social phobic patients (this
practice, subjects reach moderate levels of was part of a larger study which included
relaxation in just 20±30 seconds. They then agoraphobic and specific phobia patients).
apply their relaxation skills, first in practice and Patients in the exposure conditions experienced
then in real-life feared situations. These proce- greater reductions in anxiety and greater
dures have been used in two studies of patients increases in approach behavior than patients
with social phobia. Both studies used AR and a treated with relaxation. Therapist-guided ex-
treatment-matching approach. A study de- posure was only minimally more effective than
scribed earlier indicated that physiological self-directed exposure instructions.
reactors who received AR participated in more AlstroÈm et al. (1984) compared therapist-
social activities, made more social contacts, and directed exposure to dynamically oriented
showed fewer behavioral signs of anxiety during supportive therapy and relaxation therapy.
a social interaction test than physiological Forty-two patients were randomly assigned to
reactors who received SST (OÈst et al., 1981). one of the three treatments or a control
Jerremalm, Jansson, and OÈst (1986) used a condition (ªbasal therapyº) which included
similar strategy for physiological reactors and unspecified anxiolytic medication plus instruc-
cognitive reactors (defined by high rates of tions for self-exposure. Patients in the three
endorsement of negative cognitions after a treatment conditions also received basal ther-
behavioral test), this time matching cognitive apy. Exposure patients received therapist-
reactors with self-instructional training, a directed, prolonged exposure to moderately
highly structured cognitive-behavioral techni- difficult but common situations. Patients were
que. AR was more effective than a waiting-list instructed to remain in feared situations until
condition and as effective as stress-inoculation habituation occurred. Situation difficulty was
training (SIT) on a number of measures. There graduated and therapist assistance gradually
was no support for the treatment-matching removed. Imaginal exposure supplemented this
hypothesis and on some outcome measures, SIT procedure for some patients treated with
outperformed AR for the physiological reactors exposure.
as well. This study will be reviewed in more Patients treated with exposure evidenced
detail in Section 6.21.3.4.1. greater reductions in anticipatory anxiety and
anxiety in difficult situations, avoided less when
faced with difficult situations, and showed
6.21.3.3 Exposure-based Techniques greater improvement on a measure of global
Exposure to a phobic stimulus has been the disturbance compared with patients treated
cornerstone of behavioral treatments and is with relaxation or basal therapy alone. Ex-
viewed as a central component for effective fear posure patients appeared to lose some of their
reduction (Barlow & Beck, 1984). Thus, gains by nine-month follow-up, no longer
exposure has been evaluated in several studies maintaining an advantage over patients treated
of the treatment of social phobia. Exposure with relaxation or supportive therapy. They did,
takes many forms in these studies, varying on however, continue to outpace patients receiving
several dimensions including degree of therapist basal therapy alone on measures of situational
involvement, length of exposure sessions and and anticipatory anxiety.
total exposure time in therapy, and imaginal vs. Interpretation of the results of AlstroÈm et al.
role-played vs. actual (in vivo) exposure, to (1984) is difficult for several reasons. Patients
name just a few. There is virtually no research selected for participation in this study were first
that systematically compares the differential deemed to be ªunsuitable for insight-oriented
effects of these dimensions of exposure in the psychotherapyº and it is unclear how this
treatment of social phobia. exclusion effects the generalizability of the
findings. Furthermore, differences between
groups at pretreatment on gender, other
6.21.3.3.1 Review of empirical studies of
demographic characteristics, and level of im-
exposure-based tehniques
pairment, and the unsystematic application of
Fava, Grandi, and Canestrari (1989) pro- treatment within and across groups further
vided instructions for self-directed exposure to compromises the reliability of these findings.
10 social phobics in an uncontrolled study. Emmelkamp, Mersch, Vissia, and van der
Eight treatment sessions produced significant Helm (1985) compared exposure with RET and
reductions in self-report and observer-rated SIT in the treatment of 34 patients meeting
486 Social Phobia
DSM-III criteria for social phobia. Exposure and approved by all significant people in one's
consisted of within-session role-plays (such as life and the belief that it is necessary to be
public speaking and maintaining eye contact) completely competent, adequate, and achieving
and homework instruction to attempt in vivo in all areas to be worthwhile. Social phobics may
exposure (such as making inquiries in shops and easily be understood to fall victim to these two
speaking to strangers). The cognitive treatments (and other) irrational beliefs. RET is designed to
will be described in Section 6.21.3.4.1. confront and contradict irrational beliefs
Exposure resulted in reductions in social through frank discussion, encouragement, and
anxiety and general psychopathology at post- persuasion, with the ultimate goal to change a
treatment assessment and additional improve- person's basic philosophy and reliance on
ments at one-month follow-up. At post-test, irrational beliefs (Ellis, 1972).
exposure patients evidenced significantly great- Unlike RET, Beck's cognitive therapy focuses
er reductions in heart rate before and after a less on generalizations about one's misfortunes
behavior test than patients treated with RET or and more on errors of cognitive processing
SIT. No other differences favored exposure at which lead to distortion and misinterpretation
post-test or follow-up. (Beck, 1976). These so-called cognitive errors
In a previously described treatment-matching include selective abstraction (focusing on a
study, Wlazlo et al. (1990) compared individual- detail out of context and missing the significance
and group-administered exposure with SST for of the situation) and arbitrary inference (reach-
patients classified as having primary social skills ing conclusions without adequate evidence or
deficits or primary social phobia. Within-group contrary to available evidence). Cognitive
changes occurred in all treatments on most therapy involves openly challenging these types
measures. Patients with primary social phobia of errors with logic and Socratic discussion.
who received group exposure reported less fear Ultimately, patients begin to view their situation
of social contact and greater ability to refuse in more realistic and adaptive terms. To be
requests than patients with social skills deficits precise, however, there is really no such thing as
treated with group exposure. As we noted a cognitive therapy which is not also behavioral,
previously, problems with this study (e.g., all because these therapies rely heavily on exposure
groups received instruction for self-exposure) to feared situations and the conduct of
compromise our ability to determine the relative behavioral experiments.
benefits of these treatments.
6.21.3.4.1 Review of empirical studies of
6.21.3.4 Cognitive-behavioral Techniques cognitive-behavioral technique
Social phobia has been a focus of attention of In a study briefly described earlier, Emmel-
cognitive theorists for a considerable time. For kamp et al. (1985) compared RET and SIT with
example, Butler (1985, p. 651) asserted that role-played and in vivo exposure. RET focused
patients' ªthoughts and attitudes seem to play a on challenging irrational beliefs commonly held
central role in the maintenance of social by social phobic persons. SIT is a modified
phobia.º Butler went on to suggest that version of Meichenbaum's (1985) stress-inocu-
treatment of social phobia which does not lation training without relaxation procedures.
address these cognitive factors may be less SIT patients identify and record negative
effective. Several researchers have proposed thoughts and affective responses that occur in
models of social phobia (see earlier discussion) social situations. Patients then work with their
which highlight cognitive factors as the likely therapist to develop more realistic appraisals
maintaining mechanism of social phobia in the designed to increase coping with anxiety-
face of exposure to feared situations (e.g., Clark provoking situations. Neither SIT or RET as
& Wells; 1995; Rapee & Heimberg, 1997). conducted in this study included an exposure
Cognitive-behavior therapy (CBT) draws component.
heavily from two sourcesÐRET, first put forth Patients in the cognitive treatments reported
by Ellis in the early 1960s, and Beck's cognitive reductions in social anxiety, general psycho-
therapy, first put forth a decade later. Although pathology, and irrational beliefs. RET patients
various labels exist for what is termed CBT, reported less social anxiety on one measure at
most cognitive techniques share their origins post-test and maintained this difference one
and many common features with these two month later compared with SIT patients.
approaches. RET is based on the principal that Additional improvement occurred in both
human beings are prone to fall victim to one or conditions during the brief follow-up period
more irrational beliefs which are common in and patients in both cognitive treatments
Western civilization (Ellis, 1962). Examples reported fewer irrational beliefs than patients
include the belief that it is essential to be loved treated with exposure.
Jerremalm et al. (1986) classified 38 social patients. Patients receiving SRR (singularly or
phobics as physiological reactors (greater heart as part of the combined treatment) showed
rate reactivity during a role-played social significant improvement on social anxiety, trait
interaction) or as cognitive reactors (relatively anxiety, and irrational beliefs; improvement
greater frequency of negative thoughts during was seen on 16 of 19 measures overall. SCD
the interaction). Using a treatment-matching treated patients improved on 10 of 19 measures.
paradigm, patients of each type were assigned SRR patients also reported lower trait anxiety,
randomly to either AR, SIT, or a wait-list cond- fewer irrational beliefs, and lower anxiety
ition. Physiological reactors receiving either during a behavior test than SCD patients.
treatment were more improved than waiting- Combined treatment patients reported less
list patients on measures of anxiety and heart anxiety about the prospect of giving a speech
rate during the behavior test. Also, physiological and less anxiety during a behavior test than
reactors assigned to SIT reported fewer negative SCD patients. At a nine-week follow-up
thoughts and more positive thoughts than the assessment, patients on active treatments gen-
control group. Cognitive reactors receiving erally maintained their gains. Patients treated
either treatment were also significantly im- with SRR had significantly greater reductions in
proved. When treated with SIT, cognitive trait anxiety, fear of negative evaluation, and
reactors improved more than when treated with irrational beliefs than SCD patients.
AR on three of seven self-report measures. No Stravynski (1983) treated a single patient
advantage was found for the physiological with psychogenic vomiting which occurred
reactors treated with AR, and on two measures, whenever the patient visited his girlfriend's
SIT was actually more effective than AR. parent's home and when he went to theaters and
In another study described earlier, Mersch bars. In vivo exposure was combined with social
et al. (1989) also used a treatment matching skills training and cognitive restructuring and
model, comparing RET with SST in the all components were introduced simulta-
treatment of social phobic patients classified neously. Vomiting was eliminated after seven
as either cognitive or behavioral reactors. Both sessions, and anxiety in three of four target
groups of patients evidenced numerous im- situations dramatically decreased. Seven
provements regardless of treatment including months following treatment the patient con-
reductions in social anxiety. Contrary to the tinued to perform the target behaviors, and an
treatment-matching hypothesis, patients trea- informal follow-up after two years suggested
ted with SST improved on measures of cognitive that gains had been maintained. In an uncon-
functioning and patients treated with RET trolled study, Mersch, Hildebrand, Lavy,
rated themselves as more skillful. Wessel, and van Hout (1992) administered a
unique combination of RET and paradoxical
interventions to three patients with fears that
(i) Combined cognitive-exposure techniques
public embarrassment would result from the
Several studies have combined cognitive occurrence of their physiological symptoms of
techniques with exposure more fully. Kanter anxiety (e.g., blushing, sweating, trembling).
and Goldfried (1979) first evaluated a cognitive Paradoxical techniques incorporated exposure.
treatment with 68 volunteers who appear to All patients improved on a broad array of
have met diagnostic criteria for social phobia measures and frequency of feared symptoms
(this study preceded publication of DSM-III). was reduced, although anxiety experienced on
In this variation of RET known as systematic occurrence of these symptoms remained high.
rational restructuring (SRR; Goldfried, De- While these gains were maintained at an 18-
Centeceo, & Weinberg, 1974), patients use month follow-up, methodological considera-
imagery of anxiety-provoking situations to tions limit conclusions about the efficacy of this
identify unrealistic thoughts, logically challenge treatment approach.
those thoughts, and substitute more adaptive Heimberg, Becker, Goldfinger, and Vermil-
ones in their place. Anxiety experienced during yea (1985) treated seven social phobic patients
imagery cues the patient to begin cognitive in small groups with a combination of cognitive
procedures. SRR was compared to self-control restructuring, imaginal exposure, exposure to
desensitization (SCD; Goldfried, 1971) in which simulated social situations, and homework
patients respond to imagery-induced anxiety assignments for in vivo exposure. Cognitive
with progressive relaxation, to the combination restructuring was conducted immediately fol-
of SCD and SRR, and to a wait-list control. lowing exposure exercises and focused on
Patients were treated in groups of 8±10 for seven negative cognitions related to the simulated or
weekly 1.5-hour sessions. imagined situation. These procedures resulted
Patients in the three active treatments in significant reductions in social anxiety,
improved significantly more than waiting-list general anxiety, and fear of negative evaluation
488 Social Phobia
immediately following treatment. Patients rated (ii) Cognitive-behavioral techniques and

their own performance during a behavior test as pharmacotherapy
higher in quality, and they were rated by others
as less anxious. Attributions for negative out- Several pharmacological treatments of social
comes became less internal and stable. For six of phobia exist and have been studied to varying
the seven patients, gains were maintained at a degrees. Although pharmacological approaches
six-month follow-up on both self-report and will not be reviewed here (see Liebowitz &
behavior test measures, whereas one patient's Marshall, 1995; Potts & Davidson, 1995, for
anxiety returned to baseline levels. reviews of pharmacological treatments), three
Based on this preliminary study, Heimberg studies have compared cognitive restructuring
et al. (1990) removed imaginal exposure and plus exposure with pharmacological treatments.
developed a more highly integrated treatment Two of those studies used Heimberg's CBGT.
combining cognitive restructuring and exposure Gelernter et al. (1991) compared CBGT with the
exercises. In this treatment package, referred to monoamine oxidase inhibitor phenelzine, the
as cognitive behavioral group therapy for social triazolobenzodiazepine alprazolam, and pill
phobia (CBGT), cognitive restructuring is placebo. Patients assigned to receive medication
employed before, during, and after simulated or placebo were also provided with self-
and in vivo exposures (the latter comprise exposure instructions, a procedure that makes
homework assignments). CBGT is described this study more clinically relevant but reduces
in more detail by Heimberg et al. (1995). the distinctiveness of treatments. Patients in all
Heimberg et al. (1990) compared CBGT with four groups experienced significant improve-
an attention-placebo group in the treatment of ment on all measures, with few differential
49 social phobic patients. The comparison effects. Patients treated with phenelzine were
treatment combined educational presentations more improved than other patients on a
on topics relevant to social phobia and guided measure of trait anxiety at two-month follow-
peer support. Patients were assigned randomly up, but similarities among outcomes far out-
to either CBGT or the placebo group. At post- weighed differences. At follow-up, patients
test, patients treated with CBGT were less receiving phenelzine or CBGT maintained their
anxious during a behavior test and were rated as gains while alprazolam patients did not. Several
less severely impaired by clinical assessors. methodological concerns complicate interpreta-
CBGT patients maintained their gains at a tion of these results. These include sole reliance
six-month follow-up and reported more positive on self-report measures, the inclusion of self-
and fewer negative thoughts during the beha- exposure instructions in the medication and
vior test. Eighty-one percent of CBGT patients, placebo conditions, and an increase in the
compared with 47% of placebo patients, were recommended number of patients in each
rated as having made clinically significant CBGT group from six to 10.
improvement at follow-up. A large-scale, multisite collaborative study
Heimberg, Salzman, Holt, and Blendell compared CBGT, phenelzine, pill placebo, and
(1993) reassessed 19 of the patients who the attention-placebo treatment employed by
participated in the Heimberg et al. (1990) study Heimberg et al. (1990). Heimberg et al. (1997)
an average of 5.5 years following treatment randomly assigned 133 patients to 12 weeks of
(range 4.5±6.25 years). Although these patients one of the four treatments. Patients judged to be
were less impaired at pretest than patients who responders to CBGT or phenelzine continued
did not participate in this follow-up, there were for an additional six months of therapy with
no differences between participating CBGT and reduced (monthly) contact and six months of
control patients. Nonetheless, generalizations treatment-free follow-up. CBGT and phenel-
based on these results should be limited to less zine produced equivalent response rates, super-
impaired patient populations. ior to both control conditions, after 12 weeks of
Within these limits, this study supports the treatment. Phenelzine led to faster response and
long-term efficacy of CBGT. Specifically, was somewhat more effective than CBGT on
CBGT patients were rated by independent some measures after 12 weeks. During the six-
assessors as less severely impaired and as month untreated follow-up, CBGT patients
experiencing less interference at work, in social were less likely to relapse than patients treated
activities, and in their family life compared with with phenelzine (Liebowitz et al., 1997). This
attention-placebo patients. Eighty-nine percent was especially the case for patients with
of CBGT patients and 44% of placebo patients generalized social phobia. A study examining
were judged to be significantly improved. the efficacy of the combination of these two
CBGT patients were also rated as evidencing treatment modalities is underway.
more social skills and less anxiety during a The third study comparing pharmacological
behavioral test. treatments with cognitive restructuring and
exposure treated 34 musicians with perfor- utilized coping technique. Problems with pro-
mance anxiety (Clark & Agras, 1991). The cedures in the exposure condition are elabo-
combination of cognitive restructuring, expo- rated elsewhere (Juster, Heimberg, & Holt,
sure, and relaxation was evaluated with and 1996) but include limitation on the total time
without the anxiolytic medication buspirone. spent on exposure and its procedures, and low
Musicians were randomly assigned to one of credibility ratings for the exposure-only condi-
four conditions: cognitive-behavioral treatment tion possibly due, in part, to the filler treatment.
with buspirone, cognitive-behavioral treatment Mattick and his colleagues conducted two
with placebo, buspirone alone, and placebo studies examining exposure and cognitive
alone. Generally, patients treated with techniques in various combinations (Mattick
cognitive-behavioral therapy experienced im- & Peters, 1988; Mattick, Peters, & Clarke,
provement on several important outcome 1989). The first study compared therapist-
variables, whereas buspirone was no more assisted exposure with and without cognitive
effective than placebo. Cognitive-behavioral restructuring (Mattick & Peters, 1988). In
therapy plus placebo was the most effective contrast with the study by Butler et al. (1984),
treatment combination, and these patients no filler treatment was used. Both treatments
outperformed all others on a measure of yielded similar post-treatment outcomes, in-
confidence in performing at a one-month cluding reductions in avoidance, phobic sever-
follow-up assessment. ity, and depression. At three-month follow-up,
patients in the combined treatment group
completed a greater percentage of tasks during
(iii) Component analysis of cognitive-exposure
a behavioral test and evidenced lower avoidance
techniques
and higher scores on composite measures of
From this review, it is clear that the improvement and end-state functioning than
combination of cognitive restructuring and patients treated with exposure alone.
exposure can be a highly effective treatment In their second study, Mattick et al. (1989)
for social phobia. However, these studies do not compared the same conditions as in the previous
tell us whether or not it is necessary to combine study, but added a cognitive restructuring only
these two treatment approaches and whether condition and a wait-list condition. Patients in
the addition of cognitive restructuring to the three active treatments completed more
exposure techniques is in any way more effective tasks during a behavior test and scored lower on
than exposure alone. A series of studies has self-report measures of phobia severity and
examined this issue and is reviewed below. avoidance than patients on the wait-list.
Butler, Cullington, Munby, Amies, and Exposure only and the combined treatment
Gelder (1984) compared exposure only with were more effective than cognitive restructuring
exposure plus anxiety management training alone in terms of the tasks completed during the
(Suinn & Richardson, 1971). The latter com- behavior test. At the three-month follow-up,
prises relaxation, distraction, and rational self- however, patients in the cognitive restructuring
talk. Patients in the exposure-only condition only and combined treatment conditions con-
received a filler treatment which occupied the tinued to improve, whereas patients receiving
same amount of time as anxiety management exposure only appeared to deteriorate. Patients
training. After treatment, patients in both in the combined treatment condition experi-
exposure conditions were superior to a wait- enced the greatest improvement on percentage
list group, having achieved reductions in phobic of behavioral tasks completed.
severity, anxiety during a behavior test, diffi- Not all studies support the combination of
culty during social situations, general anxiety exposure and cognitive techniques. In fact, the
and depression. Combined treatment patients majority of studies on this issue do not support
achieved lower scores on two measures of social the need for cognitive procedures to be added to
anxiety compared with patients receiving ex- exposure techniques. Biran, Augusto, and
posure only. Wilson (1981) examined the effect of adding
Differences between combined treatment cognitive therapy to in vivo exposure in a
patients and exposure-only patients were main- multiple-baseline-across-subjects design. Two
tained or increased at a six-month follow-up of three women with fears of writing in public
assessment. Fully 40% of patients receiving received five sessions of cognitive restructuring
exposure only sought further treatment in the followed by five sessions of exposure. The third
following 12 months, whereas no combined patient received exposure only. Exposure,
treatment patient did so. Although anxiety conducted according to a standardized hier-
management training is not a solely cognitive archy of feared writing situations, produced
intervention, post hoc analyses suggested that significant increases in the number of writing
rational self-talk was the most frequently tasks performed. Cognitive restructuring did
490 Social Phobia
not enhance the effectiveness of exposure. exposure techniques. Scholing and Emmelkamp
However, reductions in fear ratings during (1993a) treated 30 social phobics with primary
performance of the exposure situations were fears of blushing, sweating, or trembling.
less clearly tied to specific treatment. Individual treatment was administered in two
At nine-month follow-up, avoidance of four-week blocks separated by a four-week
feared situations remained low. However, fear period of no treatment. Patients were randomly
in those situations returned to pretreatment assigned to either in vivo exposure followed by
levels. Although no further follow-up was RET, RET followed by in vivo exposure, or
conducted, one might speculate that this integrated RET and in vivo exposure. It is
desynchrony between approach behavior and important to note that in the integrated
anxiety could predict poor long-term outcome. treatment, exposures were never conducted
In fact, two of the three patients sought during the therapy session. Thus, the primary
additional treatment during follow-up, one focus of integrated therapy sessions was on
for unspecified ªsocial issues,º the other for changing irrational beliefs relative to situations
further anxiety reduction. All three indicated which would then be the focus of home-based
some disappointment that their anxiety reduc- exposure exercises. All treatments produced
tion had not been maintained. Although this substantial and equal improvements on com-
study has been criticized for several reasons, posite measures of avoidance of target situa-
probably the most critical concern involves the tions, irrational cognitions, and somatic
total segregation of treatment components in a complaints. No differences were evident after
manner inconsistent with clinical practice and three-month follow-up.
which may reduce treatment effectiveness Scholing and Emmelkamp (1993b) conducted
(Heimberg, 1989; Heimberg, Dodge, & Becker, an essentially similar study with 73 generalized
1987). social phobics. Patients were randomly assigned
More recently, Taylor et al. (1997) randomly to exposure only, exposure followed by RET, or
assigned 65 patients to eight sessions of integrated RET and exposure. Treatments were
cognitive restructuring without exposure or provided in blocks as in the previous study and
eight sessions of the filler treatment used by included both individual and group modalities.
Butler et al. (1984). Cognitive restructuring was Patients assigned to integrated treatment in the
clearly more effective than the filler condition individual modality had no exposures during
after this initial phase of treatment. Following their sessions. Patients assigned to exposure or
an assessment, both groups received additional integrated RET and exposure in the group
sessions of exposure to determine if treatment modality received exposure during sessions,
response would be facilitated. There were no although discussion of maladaptive cognitions
differences between groups after exposure on a was clearly the primary emphasis in the
battery of self-report measures administered at integrated treatment. Patients in the integrated
the three-month follow-up. Thus, after both treatment reported more somatic complaints
groups were treated with exposure, patients who than patients in the other two treatments after
received the filler treatment were as improved as the first treatment block. No significant differ-
patients who had previously received cognitive ences were found between treatments after the
restructuring. second block or at three-month follow-up.
Hope, Heimberg, and Bruch (1995a) com- Importantly, fully 47% of the exposure-only
pared exposure alone with the complete CBGT patients and 28% of the RET-followed-by-
protocol described earlier to determine the exposure patients sought additional treatment
relative importance of the cognitive component. in the 18 months following their participation
Both conditions were more effective than a wait- (Scholing & Emmelkamp, 1996). Only 6% of
list condition after 12 weeks of treatment. the patients in the integrated treatment condi-
Patients treated with CBGT reported less tion sought further treatment during this period.
anxiety during an individualized behavior test While the authors reported no statistical
at post-treatment, but this was the only measure analysis of this finding, it is similar to that
in which the full protocol outperformed ex- reported by Butler et al. (1984).
posure alone. Differences between exposure and Mersch (1995) compared exposure alone with
CBGT at post-treatment, most of which favored an integrated treatment combining in vivo
exposure, disappeared at the six-month follow- exposure, RET, and social skills training. As
up, at which time the two treatments were in the individual treatments administered by
equally effective. In this trial, however, CBGT Scholing and Emmelkamp (1993a, 1993b), no
was less effective than in other studies of this exposures were conducted during treatment
protocol. sessions. Thirty-four patients were randomly
Three studies employed RET in assessing the assigned to either a wait-list control group or to
efficacy of cognitive therapy with and without one of the two treatment groups. Sixteen
sessions of individual therapy were provided, pret. Several studies did not support the need for
and follow-up assessments were conducted at the integration of exposure and cognitive
three months and 18 months. Both treatments restructuring, while others suggest that com-
were superior to the wait-list control at post- bined treatment is superior and that additional
test, but there were no differences between gains are more likely during the follow-up
exposure alone and the integrated treatment. At period. The meta-analyses produced contra-
18-month follow-up, patients in both active dictory results regarding this question as well.
treatments achieved additional gains on self- Thus, the question of the importance of the
report measures of social anxiety, but they still integration of exposure and cognitive restruc-
did not differ from each other. turing in the treatment of social phobia remains
unresolved. However, cognitive change may be
central to good clinical outcomes, regardless of
(iv) Results of meta-analyses
how it is produced. The importance of cognitive
An alternative method of examining the change is demonstrated by studies in which
relative importance of treatment components change in fear of negative evaluation from
is meta-analysis, a technique which compares pretreatment to post-treatment predicts end-
averaged effect sizes for particular treatments or state functioning (Mattick & Peters, 1988;
treatment components across several studies. Mattick et al., 1989). However, cognitive
Three meta-analyses examining cognitive-beha- interventions may not be necessary to engender
vioral treatment of social phobia have been cognitive change. Exposure alone may provide
conducted (Feske & Chambless, 1995; Gould, sufficient disconfirmatory information to alter
Buckminister, Pollack, Otto, & Yap, 1997; dysfunctional beliefs (Hope et al., 1995a;
Taylor, 1996). In the meta-analysis by Feske Mattick & Peters, 1988; Newman, Hofmann,
and Chambless (1995), exposure plus cognitive Trabert, Roth, & Taylor, 1994).
restructuring and exposure alone did not differ Turk, Fresco, and Heimberg (in press) outline
in dropout rates and yielded similar effect sizes several additional issues that should be con-
on both post-treatment and follow-up measures sidered before conclusions are drawn regarding
of social anxiety, cognitive symptoms, and the necessity of cognitive interventions and the
depression/anxiety. Gould et al. (1997) evalu- role of cognitive change in successful treatment
ated 24 studies which examined cognitive- outcome. The first issue concerns the measures
behavioral and pharmacological therapies used to demonstrate cognitive change. Ques-
which included a control condition. CBT and tionnaire measures commonly used to assess
pharmacological treatment produced similar cognition correlate highly with social phobia
effect sizes for reductions in social anxiety, and symptom measures. When change is noted on
both effect sizes were significantly different these measures, the observed gains may be a
from zero. Within CBT, exposure with cognitive product of change in the portion of variance
restructuring and exposure alone yielded similar shared with symptom measures. In other words,
attrition rates and effect sizes. Lastly, Taylor change on commonly used questionnaire mea-
(1996) examined 42 treatment studies and sures of cognition may reflect changes in
compared six conditions: waiting-list control, cognition, anxiety, or both (Heimberg, 1994).
placebo (the combination of pill placebo and Second, many ªpurely behavioralº interven-
attention-placebo), exposure alone, cognitive tions may implement ªexposure onlyº proce-
restructuring without exposure, cognitive re- dures in a manner which facilitates cognitive
structuring with exposure, and SST. The drop- change (Newman et al., 1994). Specifically,
out rate did not differ across the six conditions. ªexposure onlyº treatments which include
The four active therapies and placebo produced therapist and/or group member feedback
greater effect sizes than the waiting-list control; regarding patient skill, visibility of anxiety
however, only cognitive restructuring with symptoms, ability to cope with anxiety, etc.,
exposure had a significantly larger effect size share many features with cognitive approaches,
than placebo. Effects remained stable during although these aspects of therapy may not be
follow-up for all treatments. labeled as cognitive interventions by noncogni-
tive therapists. Finally, while studies that find
equivalent outcomes for exposure vs. exposure
(v) Summary
plus cognitive restructuring typically interpret
The study of the relative efficacy of exposure this pattern to mean that cognitive restructuring
vs. combined cognitive restructuring plus does not add to the efficacy of exposure,
exposure represents one of the critical issues alternative interpretations are available. It is
in the treatment of social phobia. However, this also reasonable to suggest that cognitive
collection of studies presents results that are restructuring activities reduce the amount of
contradictory, confusing, and difficult to inter- exposure necessary for effective treatment.
492 Social Phobia
6.21.3.5 Psychodynamic Formulations in nature (with the social phobic individual

usually taking on a submissive role but
Little has been written about the psychody- desperately wanting to be the dominant figure).
namic perspective on social phobia, and even This bias towards a defensive posture leads the
less research specifically testing psychodynamic social phobic individual to become hypervigi-
assumptions has been conducted. Still, psycho- lant for threat cues in others' behavior, to be
dynamic theory and therapy remain popular overly competitive or overly submissive, and to
and merit some discussion here. Gabbard (1992) become hypersensitive to criticism. Although
proposes a traditional psychodynamic concep- both the competitive and cooperative systems
tion of social phobia. In one formulation, social may be adaptive in different situations, social
interaction characterized by anxiety and with- interaction is typically cooperative. Similar to
drawal are presumed to be manifestations of Gabbard's (1992) perspective, it is believed that
important early developmental events re-ex- early interaction with parental figures stimu-
perienced as adult anxiety symptoms. Specifi- lates overuse of the defensive system. In
cally, it is thought that some social phobics have particular, parents may focus the child's atten-
an unconscious wish to be the center of attention tion on ªdangersº in the social environment or
and to receive positive affirmation by those in conversely overprotect them unnecessarily.
their environment. This wish produces an Children may experience their parents as
immediate shame reaction in the social phobic controlling, hostile, or rejecting, and parents
individual believed to be associated with early may communicate that caring is contingent on
negative shame-producing experiences with certain behaviors such as a submissive attitude
disapproving parental figures. Social phobia is with parents. Although some research does
also thought by some to be related to separation support early experiences as potential progeni-
anxiety. In this variation, social phobia is seen as tors of later social anxiety in adult social
a recapitulation of childhood struggles with phobics, this does not necessarily provide
individuation and attachment. Efforts to be- support for other aspects of these psychody-
come increasingly autonomous are countered namic formulations.
by fears of losing parental love. According to
Gabbard (1992), certain characteristic internal 6.21.4 PREDICTORS OF OUTCOME
representations are common to psychodynamic
views of social anxiety including criticism, Although there are now effective treatments
ridicule, humiliation, abandonment, and em- for social phobia, not everyone who receives
barrassment associated with parents, caregivers, treatment benefits from it. For example, Heim-
and siblings. These so-called introjects are berg et al. (1997) reported that 75% of patients
projected onto others in the social phobic who completed a 12-week trial of CBGT were
person's environment and become the object independently judged to be moderate or full
of his/her adult anxiety. responders to that treatment. These figures are
In contrast to the more traditional psycho- reduced (58%) when drop-outs are considered
dynamic perspective of social phobia, Cloitre in an intent-to-treat analysis. Clearly, many
and Shear (1995) espouse a psychobiological patients with social phobia do not benefit
model which draws heavily on ethological maximally from the treatments they receive. It
theory, especially the work of Trower and is not known whether patients who fail to
Gilbert (1989). This model posits that compe- respond to one treatment might be likely to
titive and cooperative modes of relating which respond to a different treatment, nor is it known
are important to many species are central to which patient characteristics might predispose
human social interaction as well. Specifically, a toward better or worse response to one or
competitive or defensive system of interaction is another treatment. However, several studies
characteristic in groups that develop dominance have begun to examine this issue. The majority
hierarchies. Submission and dominance are of these studies have attempted to identify
critical behaviors that maintain the organiza- predictors of response to Heimberg's CBGT
tion's hierarchical structure. A cooperative or (Brown et al., 1995; Chambless, Tran, & Glass,
safety system allows sharing of resources and 1997; Holt, Heimberg, & Hope, 1989, 1990;
effort, minimizing differences between members Hope et al., 1995b; Juster, Heimberg, & Mattia,
of the group. Hierarchies are more horizontal in 1993), whereas one other study examined
a cooperative mode and more vertical in a predictors of response to flooding (Turner,
competitive mode. Applied to social phobia, it is Beidel, Wolff, Spaulding, & Jacob, 1996). It is
hypothesized that the person with social phobia not known how these results might generalize to
is overly reliant on the defensive/competitive the prediction of outcome of other treatments.
system of relating, always treating social Demographic factors have shown little con-
interaction situations as dominant±submissive sistency in the prediction of outcome of
Summary and Future Directions 493
cognitive-behavioral therapy for social phobia. (Chambless et al., 1997; Safren, Heimberg, &
Factors such as age, gender, marital status, Juster, 1997). Both studies found expectancy to
employment, and educational status have been be a unique predictor of outcome even when
unrelated to outcome (Holt et al., 1989, 1990; other important variables were controlled. For
Juster et al., 1993). Holt et al. (1989) found age example, Chambless et al. found that higher
of onset, locus of fear, and lower scores on the expectancies at the beginning of treatment were
Beck Depression Inventory (BDI; Beck, Ward, associated with improvement on self-ratings of
Mendelson, Mock, & Erbaugh, 1961) to predict anxiety and skill even after removing the effect
outcome. Specifically, later onset, public speak- of depression. Similarly, Safren et al. found that
ing vs. social interaction fears and lower BDI expectancy was significantly associated with
scores were associated with better outcomes. improvement on a variety of self-report and
However, Holt et al. (1990) found that similar interviewer measures of psychopathology after
results all but disappeared when pretreatment controlling for pretreatment severity. Thus,
social phobia severity was statistically con- patient expectancies regarding the likelihood
trolled. Juster et al. (1993) found no relationship of obtaining benefit are a unique predictor of
between demographic factors, pretreatment outcome. As noted by Chambless et al., the
clinical measures of social anxiety and depres- mechanism by which expectancies are asso-
sion, locus of control or general anxiety and ciated with outcome is unknown and not
response to CBGT. necessarily causal.
Several studies have examined social phobia
subtype as a potential predictor of CBGT
outcome. Two studies found that patients with 6.21.5 SUMMARY AND FUTURE
generalized social phobia improved with treat- DIRECTIONS
ment as much as patients with nongeneralized
social phobics. However, because they came to Social phobia, described as the neglected
treatment more impaired than nongeneralized anxiety disorder just 13 years ago (Liebowitz
social phobics, they remained more impaired et al., 1985), has become an important focus of
after treatment (Brown et al., 1995; Hope et al., the attention of clinical psychologists and other
1995b). Patients with generalized social phobia mental-health professionals. The focus of this
were less likely to achieve high levels of endstate research has been on developing effective
functioning than patients with nongeneralized treatments as well as trying to better understand
social phobia. Heimberg et al. (1997) reported the phenomenology of social phobia. In this
essentially the same pattern of results. chapter, an overview of that effort has been
Turner et al. (1996) found that generalized provided. It is known, for example, that social
and specific social phobics experienced similar phobia is more common than once believed,
levels of distress and habituation in response to affecting nearly 8% of the US population in a
flooding techniques. Moreover, measures of given year. Social phobia affects more women
endstate functioning showed a similar pattern of than men; however, men and women seek
response to that reported above for CBGT. treatment for social phobia in approximately
Specifically, generalized social phobics' re- equal numbers. Onset of the disorder is usually
sponse to flooding was similar to the response early in life, beginning for some in childhood,
of specific social phobics, but because they while for many, it may not appear until their
began treatment more impaired, they finished teens or early 20s. Evidence points to social
treatment that way as well. Subtype differences phobia as a chronic condition when left
in response to treatment appear to reflect, for untreated, and it is not uncommon for patients
the most part, differences in severity. to wait many years before pursuing treatment.
The effect of APD diagnosis on outcome of Impairment in functioning due to social phobia
the treatment of social phobia was addressed in may be extensive, reducing occupational and
Section 6.21.1.5. To summarize, generalized educational attainment in addition to social
social phobics with and without APD show functioning. Finally, social phobia is usually
similar effects from cognitive-behavioral ther- associated with one or more comorbid condi-
apy. The presence of APD before treatment tions, especially other anxiety and mood
predicts lower endstate functioning after treat- disorders. Alcohol, drug abuse, and Axis II
ment, but as for social phobia subtype, this is disorders are common complications of social
related to pretreatment severity. phobia.
Patient expectancy regarding the benefits to The serious nature of social phobia under-
be obtained from treatment may contribute to scores the critical need for effective treatments
the outcome of cognitive-behavioral treatment for this disorder. In this chapter, the principal
of social phobia, and two studies have examined psychosocial treatment approaches for social
the expectancies of patients treated with CBGT phobia have been reviewed. These included
494 Social Phobia
SST, relaxation techniques, exposure, and sessions, raters who remain uninformed as to
various cognitive-behavioral techniques. Pa- treatment assignment, patients with few or no
tients treated with social skills training appear comorbid conditions, and a fixed follow-up
to achieve and maintain gains following treat- period (Seligman, 1995). The studies reviewed in
ment. However, as noted elsewhere, the lack of this chapter are all studies of efficacy. In
well-controlled treatment trials of SST reduces contrast, effectiveness studies establish a treat-
our ability to make strong statements about its ment's utility under real-world conditions in
efficacy (Juster & Heimberg, 1995). Despite this, which one and usually several of the conditions
SST may be an important ingredient in of efficacy studies are not met. Effectiveness
treatment of the most difficult patients with studies make sense once efficacy studies estab-
social phobia, especially those who also meet lish the empirical validity of a treatment. Thus,
criteria for APD. The efficacy of this approach the effectiveness of combined exposure and
awaits further investigation. cognitive restructuring for social phobia ap-
Relaxation techniques have had mixed suc- pears to be a timely issue.
cess in alleviating social phobia. Some studies One difficulty with efficacy studies is that the
found relaxation to be better than a wait-list sample of patients who enter a study represents
condition, while others have not. OÈst has a narrow sampling of the population of patients
reported more consistently positive results for with the disorder. Patients are often excluded
AR, a combination of relaxation and exposure from efficacy studies (e.g., due to the presence of
procedures which appears to benefit some comorbid conditions) or they may decline to
patients with social phobia. However, AR participate in a study because of concern over
procedures did less well than cognitive treat- random assignment, assignment to a placebo
ments in another study. condition, etc. The question remains whether or
Exposure has fared well as a treatment for not patients who are treated in an efficacy study
social phobia. However, as with SST, metho- respond similarly or differently to the treatment
dological problems limit conclusions about the than patients who decide not to participate or
comparative efficacy of exposure and other are excluded from participation. These latter
techniques. The bulk of studies reviewed groups may represent a substantial portion of
combined exposure with some form of cognitive the population of patients with the disorder
therapy, and several of these were methodolo- (perhaps the majority) but are often not
gically sophisticated studies which allowed represented in samples of patients for whom a
strong inference. These studies demonstrated treatment may be validated. One study of social
that exposure plus cognitive restructuring is an phobia has addressed this issue. Juster, Heim-
effective treatment for social phobia, resulting berg, and Engleberg (1995) examined subjects
in significant within-group gains and surpassing screened for participation in Heimberg et al.'s
the performance of attention-placebo control (1997) comparative treatment trial of CBGT
conditions. CBGT, in particular, has demon- and phenelzine described earlier. One group of
strated long-term efficacy as well. Despite these subjects was excluded for medical or diagnostic
positive results, other studies which examined reasons and another refused entry in to the
the components of cognitive restructuring and study, citing concerns about the side effects of
exposure separately and in combination have phenelzine as the primary reason. The remain-
yielded conflicting and contradictory findings. ing subjects were treated in the comparative
Some studies support the combination of outcome study. Subjects who refused and were
exposure and cognitive restructuring as super- excluded from the trial were treated with CBGT
ior, whereas others fail to show that the outside the controlled trial, partly in an effort to
combined approach is better. Three meta- establish the effectiveness of CBGT for a
analyses also provide equivocal evidence for broader set of patients with social phobia.
the utility of combining exposure and cognitive The three groups differed somewhat on demo-
restructuring. Future studies are needed to graphic variables including measures of socio-
address this issue further, paying special atten- economic status and social support. Despite
tion to methodological and conceptual issues these differences, the three groups of patients
raised herein. demonstrated comparable gains in CBGT,
The distinction between efficacy and effec- suggesting that results of the clinical trial may
tiveness has become a central point of discussion be extended to these other groups of patients.
(Seligman, 1995; VandenBos, 1996). Efficacy The Juster et al. (1995) study only begins to
studies determine treatment response under examine the effectiveness of CBGT and similar
relatively strict laboratory conditions. These treatments for social phobia. Further research is
conditions include the use of control groups or needed to establish the effectiveness of these
comparative treatments, random assignment, techniques outside university research centers
manualized treatments, a fixed number of and under less well-controlled conditions. Also,
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6.22
Post-traumatic Stress Disorder
LISA H. JAYCOX and EDNA B. FOA
Allegheny University of the Health Sciences, Philadelphia, PA, USA
6.22.1 DEFINITIONS 499

6.22.2 SCOPE OF THE PROBLEM 500
6.22.3 RISK FACTORS FOR CHRONIC POST-TRAUMA PSYCHOPATHOLOGY 500
6.22.4 THEORIES ABOUT PTSD 501
6.22.4.1 Psychodynamic Theories 501
6.22.4.2 Cognitive-behavioral Theories 502
6.22.4.2.1 Learning theory 502
6.22.4.2.2 Cognitive theories 502
6.22.4.2.3 Emotional processing theory 502
6.22.5 EFFICACY OF PSYCHOSOCIAL TREATMENTS FOR PTSD 503
6.22.5.1 Hypnotherapy 503
6.22.5.2 Psychodynamic Treatments 503
6.22.5.3 Cognitive-behavioral Therapy 504
6.22.5.4 Studies of Imaginal and In Vivo Exposure 504
6.22.5.4.1 Studies of eye movement desensitization and reprocessing 505
6.22.5.4.2 Studies of cognitive therapy and anxiety management training 506
6.22.5.4.3 Studies of combination therapies 506
6.22.6 PREVENTION PROGRAMS 507
6.22.7 PROLONGED EXPOSURE THERAPY FOR PTSD: THEORY AND PRACTICE 508
6.22.7.1 Mechanisms Underlying Prolonged Exposure 508
6.22.7.2 How To Implement Exposure-based Therapy 509
6.22.7.2.1 Information gathering 509
6.22.7.2.2 Breathing retraining 509
6.22.7.2.3 Education about symptoms 510
6.22.7.2.4 In vivo exposure 510
6.22.7.2.5 Imaginal exposure 511
6.22.7.3 Indications and Contra-indications 512
6.22.7.3.1 Anger 513
6.22.7.3.2 Emotional numbing 513
6.22.7.3.3 Overwhelming anxiety 513
6.22.1 DEFINITIONS disorders (DSM-III-R; American Psychiatric

Association [APA], 1987) defined a trauma as
Post-traumatic stress disorder (PTSD) is an an event that is outside the range of normal
anxiety disorder that consists of a sustained and human experience and that would be markedly
dysfunctional emotional reaction to an extreme distressing to almost anyone. However, a
stressor. The revised third edition of the normative definition of a trauma proved
Diagnostic and statistical manual of mental inadequate as epidemiological studies found
499
500 Post-traumatic Stress Disorder
high prevalence rates of traumatic experiences in mately 39% of people in the USA have
segments of the general population (e.g., experienced at least one traumatic event in
Resnick, Kilpatrick, Dansky, Saunders, & Best, their lifetime. Lifetime prevalence of PTSD is
1993). Therefore, in DSM-IV (APA, 1994) the estimated at 24% among trauma victims and at
criteria were modified to include two aspects: the 9% in the general population, with up to a third
objective characteristics of the stressor, and the (3.4%) of these cases having chronic PTSD
subjective experiences of the victim. Specifically, (Breslau, Davis, Andreski, & Peterson, 1991). In
the traumatized person must have experienced addition to individuals who meet full criteria for
or witnessed a situation involving actual or PTSD, up to 15% of the general population
threatened bodily injury or death, or threat to suffer from subthreshold symptoms (Davidson,
physical integrity, and must have felt helpless, Hughes, Blazer, & George, 1991).
horrified, or terrified during the experience. Women appear to be somewhat more likely
According to DSM-IV, PTSD symptoms fall than men to develop PTSD following trauma
into three general clusters: re-experiencing, (10.4% and 5%, respectively; Kessler et al.,
avoidance, and arousal. To be eligible for a 1995). In a national sample of women, 69% had
diagnosis of PTSD, three criteria must be met. experienced some type of trauma, and 36% had
First, the individual must re-experience the been victims of crime: sexual assault, aggravated
trauma in one of the following ways: night- assault, or the homicide of a close friend or
mares, flashbacks, intrusive thoughts, and relative. The lifetime prevalence of PTSD in this
emotional distress or physiological arousal in sample was 12.9%, with six month prevalence of
response to internal or external cues that serve 4.6% (Resnick et al., 1993).
as reminders of the trauma. Second, the The experience of trauma according to DSM-
individual must have at least three avoidance IV includes not only the direct experience of a
symptoms: avoidance of thinking about the trauma, but also witnessing or learning about a
trauma, avoidance of reminders of the event, traumatic event (APA, 1994). Symptoms can
emotional numbing, detachment or distance therefore develop in those who have little or no
from other people, less interest in activities, direct exposure to the trauma, although the
psychogenic amnesia, or a sense of a fore- symptom severity is directly related to degree of
shortened future. Finally, individuals must exposure (March, 1992). For example, ferry
experience at least two of the following arousal workers who were not among the crew of the
symptoms: sleep disturbance, hypervigilance, capsized Herald of Free Enterprise ferry man-
exaggerated startle response, irritability or ifested PTSD symptoms, presumably because
outbursts of anger, or difficulty concentrating. they identified strongly with co-workers who
If these symptoms persist for at least one month were in the ferry disaster (Dixon, Rehling, &
and cause considerable impairment in daily Shiwach, 1993). This phenomenon has been
living, a diagnosis of PTSD is appropriate. In referred to as the ªripples outwardº effect.
addition to the anxiety symptoms of PTSD Certain professionals are at risk for PTSD by
itself, there is also high comorbidity between virtue of increased probability of repeated direct
PTSD and depressive symptoms, other anxiety exposure to trauma. In one study, 26% of police
disorders, and substance abuse (Kessler, Son- officers reported symptoms severe enough to
nega, Bromet, Hughes, & Nelson, 1995), and meet symptom criteria of PTSD (Martin,
these can exacerbate dysfunction in daily living. McKean, & Veltkamp, 1986). Firefighters,
Although PTSD cannot be formally diag- emergency medical technicians, emergency
nosed unless symptoms persist for at least one room staff, and disaster workers are also
month, many individuals show marked symp- thought to be at risk. For example 30% of
toms and impairment beginning immediately firefighters of an Australian bushfire had
after a trauma and may benefit from some chronic PTSD 29 months after the event
psychological intervention. Interest in this (McFarlane, 1989).
initial reaction to trauma gave impetus to the
introduction of a new disorder called ªacute
stress disorderº into DSM-IV (APA, 1994). This 6.22.3 RISK FACTORS FOR CHRONIC
disorder includes symptoms of PTSD with a POST-TRAUMA
special emphasis on dissociative symptoms and PSYCHOPATHOLOGY
lasts anywhere from two days to four weeks
post-trauma. Factors related to risk of developing chronic
disturbance may be divided into three types:
6.22.2 SCOPE OF THE PROBLEM pretrauma factors, factors related to the
trauma itself, and post-trauma factors. We
Both the prevalence of traumatic experiences will briefly review research relevant to each of
and the rate of PTSD are alarming. Approxi- these factors.
Theories about PTSD 501
Research on demographic variables has not disbelief) have strong negative effects on victim
identified reliable predictors of who will develop adjustment, whereas positive reactions from
chronic PTSD (e.g., Foa & Riggs, 1993; Green, others have little impact on adjustment (Davis,
1994). In contrast, it appears that poor Brickman, & Baker, 1991; Ullman, 1995).
psychological and social functioning prior to Excessive anger or guilt following the trauma
the trauma renders the individual vulnerable to also appear to block readjustment (Amir, Foa,
developing chronic disturbances (Ruch & Leon, & Cashman, 1997; Riggs, Dancu, Gershuny,
1983). Also, a history of prior traumatic events Greenberg, & Foa, 1992).
in childhood or adulthood augments the Thus, a number of factors must be taken into
response to subsequent traumas (Ellis, Atkeson, account in evaluating a trauma victim, includ-
& Calhoun, 1981; Riggs, Foa, Rothbaum, & ing the nature of the trauma, the victim's prior
Murdock, 1992; Roth, Waylan, & Woolsey, psychological adjustment and trauma history,
1990; Ruch & Leon, 1983). and the level of distress in the aftermath of the
It is safe to state that traumas differ in their trauma. As will be discussed further in the
likelihood of producing PTSD. In a retro- sections on theory, the meaning of the trauma
spective study mentioned earlier, Resnick et al. and changes in beliefs about the self and world
(1993) found that 17.8% of female victims of are also important factors to consider.
aggravated assault and 12.4% of rape victims
had current PTSD. In contrast, only 3.4% of
female victims of noncrime trauma had PTSD. 6.22.4 THEORIES ABOUT PTSD
Three prospective studies of female victims of For over 100 years, reactions to trauma have
rape and nonsexual assault revealed higher rates captured the interest of theorists of psycho-
of PTSD among the former at each data point pathology. Janet (1889) was among the first to
up to three month postassault (Jaycox et al., develop an integrated theory about trauma,
1996; Riggs, Rothbaum, & Foa, 1995; Roth- suggesting extreme stressors beseige the indivi-
baum, Foa, Riggs, Murdock, & Walsh, 1992). dual with an excess of thoughts and feelings too
The severity of the trauma also appears to numerous or intense to integrate. Consequently,
influence subsequent severity of PTSD: the some individuals selectively attend away from
degree of combat exposure among Vietnam the trauma, focusing instead on trauma-irrele-
veterans predicted pathology (Foy, Sipprelle, vant thoughts and feelings. In this way certain
Rueger, & Carroll, 1984; Pitman, Altman, & trauma-related ideas become split off (disso-
Macklin, 1989), and the perception of imminent ciated) from consciousness, where they cause
life threat appears to predict post-trauma fragmented reliving of the trauma in the form of
pathology among rape victims (Girelli, Resick, visual images, somatic states, emotional dis-
Marhoefer-Dvorak, & Hutter, 1986; Kilpatrick turbances, or behavioral re-enactment. As will
et al., 1989; Resick, 1986). be evident in the discussion below, Janet's ideas
Just as traumas differ in their likelihood to about reactions to trauma have influenced both
produce PTSD, so do individuals differ in their early and contemporary theorists.
reaction to a traumatic experience. Several post-
trauma factors have been found to exacerbate 6.22.4.1 Psychodynamic Theories
symptoms. Dissociative experiences during the
traumatic encounter or immediately after have Freud's thoughts about the effects of trauma
been found to predict later distress or PTSD on the psyche have shifted over time (van der
(e.g., Bremner et al., 1992; Koopman, Classen, Kolk, Weisaeth, & van der Hart, 1996). In his
& Spiegel, 1994; Marmar et al., 1994, Nishith, early writing Freud was highly influenced by
Mechanic, Griffin, & Resick, 1995; Tichenor, Janet, elaborating the dissociation phenomen-
Marmar, Weiss, Metzler, & Ronfeldt, 1996). on (Breuer & Freud, 1955). He later aban-
Also, on average, assault victims who exhibit doned the dissociation theory, proposing
more severe initial reactions to the trauma instead that trauma reactions persist because
evidence more symptoms later on (Perry, of an association between the traumatic event
DiFede, Musgni, Frances, & Jacobsberg, and childhood repressed conflicts (Freud,
1992; Riggs et al., 1995; Rothbaum et al., 1953), thus rejecting the possibility that a
1992; Shalev, Peri, Canetti, & Schreiber, 1996) traumatic event alone can cause severe emo-
although delayed peak PTSD symptoms were tional impact. Confronted by the grim effects
associated with more severe pathology com- on people of World War I, Freud focused
pared with early peak (Gilboa & Foa, 1997). again on external reality and returned to the
Evidence on the role of social support as view that the emotional upheaval generated by
facilitating or hindering recovery is equivocal. trauma is the source of traumatic neurosis. He
Indeed, empirical studies indicate that negative suggested that the intensity of the trauma, the
social interactions (e.g., victim blame or inability to find conscious expressions for it,
and the unpreparedness of the individual cause cognitive approaches. However, the originators
a breach to the stimulus barrier and overwhelm of cognitive theory for anxiety disorders gave
the defense mechanisms (Freud, 1955). little attention to PTSD itself. They did suggest,
though, that people with traumatic neuroses do
6.22.4.2 Cognitive-behavioral Theories not discriminate between safe and unsafe
signals, and that their ªthinking is dominated
Current cognitive-behavioral theory about by the concept of danger.º They also proposed
the development and maintenance of PTSD that traumatic fear can be maintained through a
stems from two lines of thinking. First is sense of incompetence to handle stressful events
learning theory, which includes both classical (Beck, Emery, & Greenberg, 1985).
and operant conditioning principles. Second is More specific hypotheses about cognitive
cognitive or schema theories, which propose factors that mediate emotional responses to
evaluative processes as mediators in the devel- trauma were advanced by scholars who em-
opment and maintenance of pathological anxi- ployed personality and social psychology the-
ety. We will discuss how post-trauma ories (e.g., Epstein, 1991; Janoff-Bulman, 1992;
psychopathology is conceived of within these McCann & Pearlman, 1990). Central to their
two theoretical approaches and then present a theories is the concept of schemas: core
third approach, emotional processing theory, assumptions and beliefs that guide the percep-
that incorporates elements of the two within an tion and interpretation of incoming informa-
information processing framework. tion. These theories share the supposition that
processing a traumatic experience requires
6.22.4.2.1 Learning theory modification of existing assumptions. Based
Mowrer's two-factor theory (1960) has been on Piaget's (1971) model of cognitive develop-
the most influential in the explanation of the ment, it is thought that such modification is
pathological anxiety seen in PTSD. In this accomplished through two mechanisms: assim-
theory, fear is acquired through classical ilation and accommodation.
conditioning, in which a neutral stimulus (CS) Both Epstein (1991) and Janoff-Bulman
is paired with an aversive stimulus (UCS), so (1992) hold the position that people in general
that the CS comes to elicit a conditioned fear assume that the world is benevolent, the world is
response (CR). Several theorists invoked this meaningful, the self is worthy, and that these
theory to explain the symptoms of PTSD (e.g., assumptions are incompatible with a traumatic
Foa, Steketee, & Rothbaum, 1989; Keane, experience. Therefore, the victim must struggle
Fairbank, Caddell, Zimering, & Bender, 1985; either to assimilate the traumatic experience
Kilpatrick et al., 1985), such that previously into the old set of assumptions or, more often, to
neutral stimuli that were present during the change the assumptions such that they can
trauma come to elicit anxiety themselves. accommodate the traumatic experience. Ex-
Through generalization and second-order con- panding on this view, McCann and Pearlman
ditioning, additional stimuli that are associated (1990) proposed seven fundamental psycholo-
with either the feared stimuli or neutral stimuli gical need areas: frame of reference, safety,
that were present during the trauma also come dependency/trust of self and others, power,
to evoke fear. For example, words, thoughts, esteem, intimacy, and independence. Trauma,
and images acquire the capacity to cause they argue, may cause disruptions in any of
anxiety. these need areas and thereby lead to trouble-
Subsequently, avoidance behavior is estab- some emotions and thoughts or images.
lished through the process of operant condi- Drawing on both psychoanalytic and infor-
tioning. In this process, an individual learns to mation processing concepts, Horowitz (1986)
reduce trauma-related anxiety though avoid- suggested that individuals have a basic need to
ance of, or escape from, the CS. Escape and match trauma-related information with their
avoidance behaviors become established ªinner models based on old informationº (p. 92).
through the process of negative reinforcement, Recovery from trauma is a process of repetitive
via their predicted capacity to end the aversive ªrevision of both [sources of information] until
fear state. Because avoidance obstructs the they agreeº (p. 92), called the completion
realization that the CS has ceased to be followed tendency, which is reflected in the re-experien-
by the UCS, fear is maintained. cing symptoms observed in individuals with
PTSD.
6.22.4.2.2 Cognitive theories
6.22.4.2.3 Emotional processing theory
Even during the influence of Mowrer's
theory, discontent with non mediational ac- Foa and her colleagues (Foa & Jaycox, in
counts of anxiety stimulated the development of press; Foa & Riggs, 1993; Foa et al., 1989; Foa,
Efficacy of Psychosocial Treatments for PTSD 503
Zinbarg, & Rothbaum, 1992) advanced a theory in treating PTSD because processes akin to
of PTSD that integrates learning, cognitive, and hypnotic trance, such as dissociation, occur
personality theories within an information naturally and are commonly used during or
processing framework, to explain why some after a trauma. Spiegel proposes that hypnosis
individuals recover from a traumatic experience may facilitate the remembering of traumatic
while others develop chronic disturbances. The experiences that were encoded in a dissociative
starting point is the observation that emotional state.
experiences are often relived well after the Several case reports have described the
original emotional events have occurred, usefulness of hypnosis for individuals with
although the frequency and the intensity of PTSD stemming from a variety of traumas
emotional reliving usually decreases over time (e.g., Jiranek, 1993; Kingsbury, 1988; Leung,
(Foa & Kozak, 1991). When these natural 1994; MacHovec, 1983; Peebles, 1989; Spiegel,
recovery processes are impeded, psychopathol- 1988, 1989). However, most of these lack
ogy emerges. To explain this pathological methodological rigor and therefore the conclu-
anxiety, Foa and Kozak (1985, 1986) adopted sions that can be drawn from them about the
Lang's (1979) conceptual framework in which efficacy of hypnosis are limited.
fear is viewed as a cognitive structure that serves One large controlled study compared hyp-
as a program for escaping danger. Accordingly, nosis, desensitization, and psychodynamic psy-
fear is represented as a cognitive structure that chotherapy with a wait-list control group
includes three kinds of information: informa- among individuals who had experienced stres-
tion about the feared stimulus; information sors (Brom, Kleber, & Defres, 1989). The
about verbal, physiological, and overt beha- majority of the participants, however, did not
vioral responses; and interpretive information directly experience the traumatic event, but
about the meaning of the stimulus and response rather had lost a loved one. All three conditions
elements of the structure. A fear structure is produced superior improvement to the wait-list
distinguished by the information that stimuli condition on self-report measures, but no
and/or responses are dangerous. In a subse- differences across the three treatments were
quent exposition of emotional processing observed. Specifically, improvement in post-
theory, Foa and Kozak, (1991) took the trauma symptoms was 29% for psychodynamic
position that it is essentially this meaning therapy, 34% for hypnotherapy, and 41% for
information that distinguishes the fear structure desensitization, compared with about 10%
from other information structures. With regard improvement in the wait-list condition. This
to PTSD, Foa and her colleagues (Foa & study offers evidence for the efficacy of hypnosis
Jaycox, in press; Foa & Riggs, 1993) suggested and other psychosocial therapies in reducing
that two classes of pathological cognitions bereavement-related symptoms.
underlie this disorder are: the world is utterly
dangerous and the self is completely incompe- 6.22.5.2 Psychodynamic Treatments
tent; a corollary of these is the idea that
persistent PTSD symptoms are dangerous and A variety of psychodynamic concepts have
are indicators of self-incompetence. been utilized in individual and group therapy
for trauma survivors (e.g., Horowitz, 1976;
6.22.5 EFFICACY OF PSYCHOSOCIAL Yalom, 1995). For example, Horowitz's brief
TREATMENTS FOR PTSD dynamic therapy emphasizes the concepts of
denial, abreaction, catharsis, and stages of
Several types of psychosocial treatment have recovery from trauma in the treatment for
been employed for post-trauma disturbances, post-trauma difficulties. The target of this brief
including hypnotherapy, psychodynamic psy- psychodynamic therapy is the resolution of the
chotherapy, and cognitive-behavioral therapies. intrapsychic conflict arising from the traumatic
However, most outcome studies have focused experience.
on examining the efficacy of the latter (see Foa Only a few studies have been conducted to
& Meadows, 1997, for a critical review). This evaluate psychodynamic interventions for
section will review these studies. PTSD, and many have methodological diffi-
culties that make their results difficult to
6.22.5.1 Hypnotherapy interpret. One study used brief psychodynamic
therapy to address difficulties following the
Hypnosis has long been used in the treatment Beverly Hills Supper Club fire (Lindy, Green,
of post-trauma disturbances (Spiegel, 1989). Grace, & Titchener, 1983). In this study,
Freud used hypnosis to facilitate abreaction and survivors included those present at the scene,
catharsis, which he felt were necessary for rescue workers, people who lost significant
recovery. Spiegel advocates the use of hypnosis others, and individuals who identified the
bodies. Only 9 of 30 met criteria for PTSD prior PTSD, via case reports and well-controlled
to treatment. Survivors who agreed to be in the studies. In this section, we will focus on
research study but did not request psychother- controlled studies only that evaluate the efficacy
apy served as the comparison group. Patients of cognitive-behavioral programs developed to
who completed treatment exhibited somewhat ameliorate PTSD symptoms: exposure therapy,
lower symptoms than did patients who did not anxiety management training, cognitive ther-
complete treatment and the non-treated com- apy, and their combinations.
parison group did not improve as much as
treatment completers. 6.22.5.4 Studies of Imaginal and In Vivo
Another study examined the efficacy of a Exposure
group therapy based on Horowitz's (1976)
model of responses to trauma with 13 sexual Exposure therapy is a set of procedures that
assault victims (Roth, Dye, & Lebowitz, 1988). involve confrontation with feared stimuli, either
The control group comprised 13 women who in vivo or in imagination (e.g., flooding,
agreed to undergo assessements, and random systematic desensitization), which will be de-
assignment was not used. There were no clear scribed in detail in the next section. With PTSD,
effects at post-treatment, but high attrition rates exposure therapy typically includes repeated
in both the treated and control groups may have reliving of the traumatic event (in imagination)
obscured effects. Results over a longer time and in vivo confrontation with trauma-related
period showed greater improvement in the situations that evoke fear but are not realisti-
therapy. Again, methodological problems ren- cally dangerous.
der these results inconclusive. As described Three controlled studies of male Vietnam
above, a study comparing Horowitz's (1976) veterans, each examining 6±16 sessions of
brief psychodynamic therapy did as well as imaginal exposure to the traumatic experience,
hypnosis, and desensitization; all did better than have been conducted. In one study, patients were
the wait-list control group (Brom et al., 1989). given up to nine sessions of imaginal flooding
In a study of psychodynamic treatment for exposure in addition to ªstandardº treatment, or
conjugal bereavement, Marmar, Horowitz, standard treatment alone (weekly individual and
Weiss, Wilner, & Kaltreider (1988) randomized group therapies) (Cooper & Clum, 1989). In the
bereaved individuals (widows) to 12 weekly second study, imaginal exposure (45 minutes of
sessions of either brief dynamic therapy or exposure preceded by relaxation) was compared
mutual help group treatment. Although death with a no-treatment wait-list condition (Keane,
of a husband does not necessarily qualify as a Fairbank, Caddell, & Zimering, 1989). In the
DSM-IV trauma, some of the women in this third study, all patients received group treat-
study were diagnosed as having PTSD. Results ment. In addition to group treatment, half the
indicated that patients in both conditions patients received weekly imaginal exposure and
improved slightly, but there were no differences the other half received weekly individual tradi-
between groups. On one of many measures (the tional psychotherapy (Boudewyns & Hyer,
total score of the Symptom checklist, SCL-90) 1990; Boudewyns, Hyer, Woods, Harrison, &
the dynamic therapy conditions showed greater McCranie, 1990).
reduction in symptoms at follow-up. These three studies found that imaginal
Scarvalone, Cloitre, & Difede (1995) used a exposure produced some improvement in PTSD
quasi-experimental design to compare inter- compared with the control groups, but the
personal process group therapy (IPGT) with a effects were rather small. In the Cooper and
naturally occurring wait-list control in a sample Clum (1989) study, imaginal exposure improved
of female childhood sexual abuse survivors, the PTSD symptoms, but had little effect on
many of whom were diagnosed with PTSD. depression or trait anxiety. In the Keane et al.
Patients in the IPGT group improved on a (1989) study a mixed picture emerged: therapists
number of measures and fewer evidenced PTSD rated patients who received exposure as more
at post-treatment than in the wait-list group. improved on PTSD symptoms than control
However, because the evaluators were not blind subjects, but on self-report measures of PTSD
to treatment condition, the extent to which symptoms, no group differences emerged.
expectancy for improvement influenced the However, patients who received exposure did
evaluation is unknown. rate themselves as more improved on general
psychopathology measures than did those in the
6.22.5.3 Cognitive-behavioral Therapy wait-list control. Boudewyns and Hyer (1990)
found no group differences on psychophysio-
As noted earlier, cognitive-behavioral treat- logical measures, but the exposure group had
ments have been evaluated far more extensively improved more than controls on the Veterans
than have other psychosocial treatments for Adjustment Scale at the three month follow-up.
Efficacy of Psychosocial Treatments for PTSD 505
Two completed studies of female assault treatments. At post-treatment and at follow-up,

victims examined the efficacy of exposure both interventions resulted in large reduction of
treatments for PTSD in comparison to other PTSD symptoms, but no clear group differences
treatments and to wait-list controls. The assaults have emerged from the preliminary data. The
targeted for treatment occurred in all cases at second ongoing study (Foa, Jaycox, Meadows,
least three months prior to treatment, to control Hembree, & Dancu, 1996) compares 9±12
for the effect of natural decline in symptoms that sessions of PE alone with a program that
occurs shortly following an assault (Rothbaum includes PE and cognitive restructuring. Again,
et al., 1992). Exposure treatment consisted of preliminary analysis suggests that both pro-
nine twice-weekly individual sessions, seven of grams were highly effective but, unexpectedly,
which included active exposure exercises and PE alone appears slightly more effective than
two of which were devoted to information the combined treatment.
gathering and education. One study that utilized a cross-over design
In the first study (Foa, Rothbaum, Riggs, & examined the efficacy of PE with victims of
Murdock, 1991), exposure treatment (PE) was diverse traumas, comparing the efficacy of in
compared with stress inoculation training (SIT, vivo and imaginal exposure by randomly assign-
which will be described later), to supportive ing 14 patients with PTSD to one of two
counseling (SC), and to a wait-list control. conditions: four sessions of in vivo exposure
Immediately post-treatment, patients in the PE followed by four sessions of imaginal exposure;
and the SIT groups improved on all three or eight sessions in the reverse order (Richards,
clusters of PTSD symptoms. Patients in the SC Lovell, & Marks, 1994). Considerable improve-
and wait-list conditions evidenced improvement ment was observed in both groups, with
on arousal symptoms, but not on avoidance or symptom reduction between 65% and 80%
re-experiencing symptoms. A follow-up evalua- and all patients losing the diagnosis of PTSD at
tion that was conducted approximately three post-test and at one-year follow-up. Results
months after treatment revealed no differences indicated that phobic avoidance was more
between the active treatments; however, on all reduced by in vivo than by imaginal exposure,
measures of psychopathology the PE group had regardless of the order in which it was received.
less pathology. At follow-up, 55% of those
receiving PE, 55% of patients who received SIT,
6.22.5.4.1 Studies of eye movement
and 45% of those receiving SC did not meet
desensitization and reprocessing
criteria for PTSD.
The second study compared PE, SIT, and a A recently developed exposure technique
group treated with the combination of SIT and called ªeye movement desensitization and
PE with one another and with a wait-list control reprocessingº (EMDR; Shapiro, 1995), which
group. All three active treatments showed combines imaginal exposure with saccadic eye
significant improvement in PTSD symptoms, movements, is beginning to be examined in
state anxiety, and depressive symptoms at post- empirical studies. However, to date, many of the
test, and the wait-list did not improve. These outcome studies conducted have been plagued
treatment effects were maintained at the 3, 6, with methodological problems, making them
and 12 month follow-ups. On an index of good difficult to interpret.
end-state functioning (defined as 50% improve- Several studies have compared EMDR to
ment in PTSD symptoms, Beck Depression standard treatments in veterans, but none used
Inventory less than 9, and State-Trait Anxiety independent evaluations of symptoms (e.g.,
Inventory less than 40), 50% of patients who Boudewyns, Stwertka, Hyer, Albrecht, & Sperr,
received PE achieved this criterion, whereas 1993; Jensen, 1994). Another study that utilized
37% and 38% of patients who received SIT and a mixed sample of traumatized individuals, only
SIT/PE achieved the criterion, respectively; some of whom had PTSD, showed that victims
none of the patients in the control group who received EMDR reported decreases in
reached this status (Foa, Dancu, Hembree, presenting complaints and in anxiety at post-
Jaycox, & Meadows, 1997). Moreover, those test, whereas the wait-list group reported no
that received PE (PE or SIT/PE) improved more such changes (Wilson, Becker, & Tinker, 1995).
on all symptoms measures as compared with to In an attempt to evaluate the effect of the
those who did not receive PE (SIT or wait-list). saccadic eye movements, Pitman et al. (1996)
Two additional studies with female assault compared EMDR to eyes-fixed exposure in a
victims are in progress. Resick and colleagues cross-over design using male veterans. No
(Resick, Nishith, & Astin, 1996) are examining differences were found between EMDR and
the relative efficacy of PE and cognitive the eyes-fixed exposure condition on self-
processing therapy (CPT), a therapy that will reported distress within sessions, with both
be described later when we discuss combined groups showing modest gains on self-reported
symptoms. Because these studies all relied solely anxiety, as exposure and cognitive therapy do,
on self-report data, the results may reflect but instead aims to provide the patient with
expectancies for improvement after treatment ways to manage anxiety when it occurs (Suinn,
rather than specific effects of EMDR. 1974). Because of the multiple elements con-
Two studies did use independent evaluations tained in most AMT programs, it is not possible
of PTSD symptoms. The first used victims of to determine the contribution of any specific
heterogeneous traumas to compare EMDR procedure to overall outcome.
with imagery habituation training and with SIT (Kilpatrick, Veronen, & Resick, 1982)
applied muscle relaxation training (Vaughan was developed as a treatment for rape victims
et al., 1994). All three groups improved equally with chronic disturbances. Modifying Meichen-
on independent ratings of PTSD symptoms baum's (1974) stress inoculation training, it
after treatment. The second controlled study included deep muscle relaxation training,
utilized female assault victims who had PTSD, breathing control, role playing, covert model-
and found EMDR to be more effective ing, thought-stopping, and guided self-dialogue.
compared with a wait-list control group In a sample of rape victims, Resick, Jordan,
(Rothbaum, 1995). After four weekly sessions Girelli, Hutter, & Marhoefer-Dvorak (1988)
of EMDR, assessor's ratings of PTSD indicated compared the efficacy of a modified SIT,
57% symptom reduction, and a self-report assertion training, and supportive psychother-
measure indicated 74% symptom reduction, apy with a naturally occurring wait-list control
and these gains were maintained at a three group. All three treatments were equally but
month follow-up. only moderately effective in reducing trauma-
In summary, the two controlled studies that related symptoms, depression, self-esteem, and
used blind assessment provide preliminary social fears; gains were maintained at six month
evidence that EMDR is effective in the treat- follow-up on rape-related fear measures but not
ment of PTSD, but its value over and above on other measures. No improvements were
other more established treatments is as yet found in the wait-list control group.
unknown. Further studies about the efficacy of Two studies, described in Section 6.22.5.4,
EMDR are clearly needed. examined the efficacy of SIT with female rape
and nonsexual assault victims who met criteria
for PTSD (Foa et al., 1997, 1991). The SIT
6.22.5.4.2 Studies of cognitive therapy and
program in both studies was adapted from the
anxiety management training
Kilpatrick et al.'s (1982) program described
Cognitive techniques aim at teaching patients above. In the first study, both SIT and PE
systematically to examine and challenge mala- produced significantly more improvement on
daptive cognitions which are thought to under- PTSD symptoms than the wait-list group and
lie negative emotions. Early work with rape supportive counseling immediately following
victims used cognitive therapy to address post- treatment. However, patients who received PE
rape anxiety and depression, but these studies continued to improve after treatment termina-
did not evaluate PTSD symptoms per se (Frank tion, whereas patients in the SIT and supportive
et al., 1988; Frank & Stewart, 1984; Turner & counseling conditions evidenced no change
Frank, 1981). The therapy produced positive between post-treatment and follow-up (Foa
change on ratings of fear, anxiety, depression, et al., 1991). In the second study, SIT, PE, and
and social adjustment. However, some patients the combination both showed immediate and
had been recently raped, and therefore their long-term (up to one year) treatment effects as
improvement could reflect natural recovery. compared with the wait-list. However, when
Although the effects of cognitive therapy on patients who received SIT were compared with
PTSD has not yet been studied, this therapy is patients who did not, no significant differences
often included as a component of anxiety emerged on any of the measures. Also the effect
management programs. size for PE relative to the control condition was
Anxiety management training (AMT) pro- larger than that for SIT on all measures (Foa
vides patients with a repertoire of strategies to et al., 1997).
handle anxiety. These include relaxation train-
ing (Bernstein & Borkovec, 1973; Jacobson,
6.22.5.4.3 Studies of combination therapies
1938), self-instruction (Meichenbaum, 1974),
breathing retraining (Clark, Salkovskis, & The success of both PE and SIT for rape-
Chakley, 1985), biofeedback (e.g., Blanchard related symptoms spurred the development of
& Abel, 1976), social skills training (e.g., Becker, combination programs that include confronta-
Heimberg, & Bellack, 1987), and distraction tions with feared stimuli in combination with
techniques (Wolpe, 1973). AMT does not target cognitive therapy or anxiety management skills.
specific mechanisms presumed to underlie Two such programs have been studied with
Prevention Programs 507
female assault victims who manifested chronic what occurred, discussion of individuals'
PTSD and a third one is currently being thoughts during the event, description of the
evaluated. The first consisted of the combina- worst part of the event for each individual,
tion of SIT and PE (SIT/PE), already described discussion of reactions to the event, a presenta-
above (Foa et al., 1997). Contrary to the tion of common reactions to trauma by group
expectations that SIT/PE would enhance treat- leaders to normalize participants' responses,
ment benefit, all three active treatments (SIT, and a wrap-up phase.
PE, and SIT/PE) were effective in reducing These types of interventions have been
PTSD severity. In fact, it appeared that PE was applied to survivors of a variety of traumatic
superior to SIT and their combination (Foa situations, including bank employees held at
et al., 1997). Foa et al. suggested that since the gunpoint (Manton & Talbot, 1990), emergency
combined treatment was delivered in the same workers (e.g., Armstrong, O'Callahan, & Mar-
number of sessions, it is possible that patients mar 1991), and military personnel (e.g., Fitz-
did not receive as much imaginal exposure as the gerald et al., 1993). However, the efficacy of
PE group. Also, the SIT program contained these programs has not been ascertained in well-
seven different techniques, some of which may controlled studies and some uncontrolled trials
not be effective. As noted above, Foa and her suggest that the debriefing can have a deleter-
colleagues are currently examining the relative ious effect. As noted by Raphael, Meldrum, and
efficacy of PE combined with cognitive re- McFarlane (1995), randomized well-controlled
structuring to PE alone and to a wait-list control studies of such programs have not yet been
group (see Jaycox, Zoellner, & Foa, 1997, for a conducted.
case example and discussion). The recognition that victims who exhibit
The second combined program for rape severe reactions shortly after the trauma are
victims with PTSD is CPT and which has been more likely to develop chronic dysfunction
tested in a quasi-experimental design (Resick & (Riggs et al., 1995; Rothbaum et al., 1992) has
Schnicke, 1992). CPT can be conducted in a prompted researchers to implement interven-
group format. It includes education, an ex- tions that aim to prevent chronic PTSD. Foa
posure component consisting of writing the and colleagues conducted a study to compare
trauma narratives and sharing it with the PTSD severity of 10 female assault victims who
therapist and group members, and cognitive received a brief prevention (BP) program (four
restructuring. The efficacy of CPT was com- individual therapy sessions) with that of 10
pared with that of a naturally occurring wait- matched victims who underwent an assessment
list, but no random assignment was instituted. procedure (Foa, Hearst-Ikeda, & Perry, 1995).
Patients who received CPT showed significant Victims who received the brief prevention
and lasting improvement whereas those on the program showed symptom reductions of
wait-list did not. As noted earlier in the section 74%, compared with a mean reduction of
on exposure therapy, Resick (Resick et al., 33% in the assessment control group. Although
1996) is conducting a study comparing CPT the small sample size and lack of random
delivered individually with PE alone. Prelimin- assignment precludes drawing definitive con-
ary results suggest that both programs are clusions as to the efficacy of the BP, the results
highly effective and do not differ from one are encouraging, and Foa and her colleagues are
another. now studying this intervention in a larger
sample of female trauma victims.
In summary, there is no evidence to date that
6.22.6 PREVENTION PROGRAMS the commonly used crisis interventions are
effective, but they have not yet been rigorously
Many trauma researchers and mental health tested. With female assault victims, short-term
professionals emphasize the need for interven- behavioral interventions may help in preventing
tion immediately after a trauma, with the aim of chronic post-trauma problems. Foa and Mea-
preventing chronic disturbances (e.g., Bell, dows (1997) noted that one difference between
1995). While there is scant evidence in support the crisis intervention programs and the Foa,
of the efficacy of immediate intervention, many Hearst-Ikeda, and Perry (1995) study is the time
programs have followed the ªcritical incident frame in which the intervention was delivered. A
debriefingº model developed by Mitchell and typical crisis intervention is employed within
Bray (1990). This program typically includes three to four days after the traumatic event,
seven phases conducted in small groups and whereas the BP program was instituted about
delivered within three days of the traumatic two weeks post-trauma. Clinical observations
event: establishing the purpose of the debriefing suggest that during the first few days after the
and the ground rules, ªrecreatingº the event by trauma victims are still disoriented and pre-
having all participants give their perspective on occupied with immediate logistical concerns,
such as interaction with law enforcement or erroneous associations in the pathological fear
medical systems. Perhaps then a program that is structure targeted in treatment. In the case of
implemented during this period cannot be PTSD, Foa and colleagues (Foa & Jaycox, in
processed adequately to provide benefit and press; Foa & Riggs, 1993) suggested that
may even add to the already existing state of treatment should correct the mistaken beliefs
confusion. Studies should investigate the opti- that ªthe world is extremely dangerousº and ªI
mal time for the delivery of crisis interventions. [the victim] am extremely incompetent.º
As noted earlier, exposure procedures for
PTSD consist of confronting the patient with
6.22.7 PROLONGED EXPOSURE trauma-related information, thus activating the
THERAPY FOR PTSD: THEORY trauma memory (i.e., eliciting the trauma-
AND PRACTICE related fear). This activation constitutes an
opportunity for corrective information to be
Despite a wide array of treatments that are
integrated, and thus for the pathological
being employed with trauma victims, most
elements of the trauma memory to be modified.
outcome studies focus on cognitive-behavioral
Foa and Kozak (1986) suggested that fear
programs which, as note above, were proven to
reduction (habituation) within and across
be quite effective in ameliorating PTSD and
exposure sessions is an indicator that meaning
related disturbances. Of these, exposure therapy
changes in the fear structure have taken place.
seems to occupy a favored position. First,
Several studies lend support to the proposition
variants of exposure used with a variety of
that emotional engagement or fear activation
trauma populations, including veterans, assault
enhances treatment efficacy (c.f. Foa & Kozak;
victims, and sample victims of mixed traumas,
Kozak, Foa, & Steketee, 1988). Of particular
have all indicated at least some degree of
relevance to PTSD are two studies demonstrat-
success. Second, the evidence for the efficacy of
ing that emotional engagement with the trauma
exposure comes from controlled studies con-
memory during treatment predicts successful
ducted in different research centers, thus
outcome (Foa, Riggs, Massie, & Yarczower,
reducing the possibility of researchers' bias. In
1995; Jaycox, Foa, & Morral, in press).
contrast, the two controlled studies on SIT were
Several mechanisms have been proposed to
conducted in a single center, as were the studies
underlie observed improvement of PTSD (Foa
of CPT. Third, PE has the advantage that
& Jaycox, in press; Foa & Riggs, 1993). First,
compared with SIT and CPT, it is relatively
repeated, prolonged, imaginal reliving of the
straightforward and thus therapists can easily
trauma is thought to promote habituation of the
be trained to deliver it. Because of the apparent
anxiety previously associated with the trauma
advantage of PE, we will focus on PE in the next
memory, thus correcting the erroneous belief
section. We will first discuss the mechanisms
common to patients with PTSD that anxiety
thought to underlie exposure techniques as a
stays forever unless avoidance or escape is
background for understanding the subtleties of
realized. Second, deliberate confrontation with
how to implement it successfully.
the feared memory blocks negative reinforce-
ment, the process whereby relief of anxiety
6.22.7.1 Mechanisms Underlying Prolonged following cognitive avoidance of trauma-related
Exposure thoughts and feelings reinforces avoidance
behavior. Third, exposure to the trauma
Emotional processing theory discussed earlier memory in a safe and supportive therapeutic
(Foa & Kozak, 1985, 1986) posits that, setting incorporates safety information into the
regardless of the type of therapeutic interven- trauma memory, thereby refuting the belief that
tion, two conditions are required for fear remembering the trauma is dangerous. Fourth,
reduction to occur. First, the fear structure focusing on the trauma memory for a prolonged
must be activated via introduction of fear- period helps the patient to discriminate between
relevant information, because if the fear the trauma and other nontraumatic events,
structure is not activated (fear is not evoked), thereby rendering the trauma as a specific
the structure would not be available for occurrence rather than a representation of a
modification. In other words, successful treat- dangerous world and of an incompetent self.
ment requires that the patient be engaged Fifth, successful reliving changes the belief that
emotionally with the feared or traumatic PTSD symptoms are a sign of personal
material. Second, new information must be incompetence to a belief that they are a sign
provided that includes aspects that are incom- of courage and competence. That is, the patient
patible with the pathological elements, so that realizes that the distress experienced during
these can be corrected. Accordingly, successful reliving (PTSD symptoms) does not lead to
therapy can be understood as correcting anticipated loss of control or ªgoing crazy.º
Prolonged Exposure Therapy for PTSD: Theory and Practice 509
Sixth, prolonged, repeated reliving of the aftermath. This discussion provides an oppor-
traumatic event allows the patient to focus on tunity to express empathy and personal concern
specific elements of the trauma that drive with the well-being of the patient. The therapy is
negative evaluations about themselves, and to presented as a collaborative effort, where the
modify those evaluations. For example, a 25- therapist and patient work together to achieve
year-old patient who suffered from PTSD specific goals. With trauma victims, the explicit
following a rape by an acquaintance was goal is the reduction of PTSD symptoms. Often
convinced at the beginning of treatment that patients are preoccupied with a number of other
she was weak because she had not been able to life issues, such as relationship problems, work
prevent the rape. Through the process of stress, or parenting issues. These issues, while
imaginal reliving, she spontaneously realized important, can divert attention away from the
ªHe was a very big man, and I am small,º and work on trauma-related disturbances and
this realization helped to modify her negative hinder treatment efficacy. Therefore, the thera-
self-image. pist and the patient should come to an under-
In addition to the six mechanisms suggested standing from the outset that such issues will be
above, Foa and Riggs (1993) suggested that the set aside to be addressed after the exposure
fear structures of traumatic memories are more therapy has successfully been implemented. If
disorganized than nontraumatic memories. A daily crises around such issues are too pressing,
disorganized memory, they proposed, is parti- the therapist and the patient may decide to delay
cularly resistant to modification. Repeated, exposure therapy.
prolonged trauma reliving generates a more
organized memory record that can be more
6.22.7.2.1 Information gathering
readily integrated with existing schemas. Sup-
port for this contention comes from a study Therapy begins with a comprehensive eva-
analyzing the victims' narratives of the trauma luation of PTSD and related symptoms, as well
during exposure (Foa, Molnar, & Cashman as information about the trauma itself. Objec-
1995). Indices of disorganization, such as tive characteristics of the trauma (e.g., extent of
unfinished thoughts and repetitions, decreased injury, time of day, characteristics of assailant)
from the first to the last narrative and this are important for treatment planning, so that
decrease was correlated with improvement. the therapist can plan exposures that effectively
Most of the mechanisms discussed above are address trauma reminders. Subjective factors of
also thought to operate in in vivo exposure. the assault (e.g., fear of death, dissociation
However, the most salient mechanism during in during the trauma) are also important, since
vivo exposure is the correction of overestimates they will help guide the therapist to include these
of the probability of danger. As will be details in the imaginal reliving. A detailed
described in the next section, the trauma victim trauma history will help the therapist identify
with PTSD often comes to fear a certain time of the trauma or traumas that generate PTSD
day, a physical characteristic of an assailant, or symptoms and make it the focus of treatment. In
a part of the city because the fear has generalized some cases, it is possible to work on more than
to situations that bear similarity to the original one traumatic event sequentially during the
trauma even when he or she is objectively safe. course of treatment, especially if the traumas are
Some situations are avoided because they are similar.
reminders of the trauma and thus elicit distress
and PTSD symptoms. Repeated confrontation
6.22.7.2.2 Breathing retraining
with such objectively harmless situations is
thought to prompt a more realistic appraisal of Since exposure techniques involve direct
danger. confrontation with feared stimuli, PTSD symp-
toms often increase in the beginning of therapy
and this should be discussed with the patient
6.22.7.2 How To Implement Exposure-based before exposure sessions begin. Training pa-
Therapy tients to use a simple relaxation technique helps
ease this initial increase in distress. We have
Often, cognitive-behavioral therapy (CBT) chosen breathing retraining in our program
researchers neglect to discuss the therapeutic because of its versatility: patients can use this
relationship when reporting outcome data. technique in almost any life situation without
However, in CBT, just as in any other disruption of their activity or attracting the
therapeutic environment, the therapist-patient attention of others. Teaching this technique at
alliance is indispensable. This is usually estab- the end of the first session seems to help the
lished in the first two sessions when the therapist patient calm down after discussing in detail the
elicits information about the trauma and its traumatic experiences.
In breathing retraining the patient is taught to the patient to their pretrauma level of function-
inhale a ªnormalº amount of air, and then to ing. The rationale is explained as follows:
exhale very slowly (four or five seconds). During
exhalation, the patient is asked to repeat the
In this program, we are going to focus on the fears
word ªcalmº or ªrelaxº mentally and to hold his
that you are experiencing, and your difficulty
or her breath for about four seconds before coping, both of which are directly related to your
inhaling again. Ideally, the therapist would assault. We've talked about the feelings, thoughts,
practice this technique in the session, and to and memories that are connected with the assault.
make an audiotape of the instructions and the We've also talked about some of the ways in which
demonstration for the patient's use at home. you are coping with that distress, such as avoiding
Patients are instructed to practice the breathing situations and memories that remind you of the
when they are relatively calm at first, and then assault.
begin implementing the technique when they are Although most of the symptoms that you and I
anxious. have talked about gradually decline with time after
the trauma, for many victims like yourself, some of
these symptoms endure and continue to cause
6.22.7.2.3 Education about symptoms marked distress. It is possible to spend up your
recovery process by understanding what causes
Patients with PTSD interpret PTSD symp- your reactions.
toms as a sign that they are ªlosing their minds,º A major factor is avoidance of situations,
or ªgoing crazy.º It is extremely important to memories, thoughts, and feelings. It is quite
educate the patient about common reactions to normal for people to want to escape or avoid
trauma in order to provide them with a memories, situations, thoughts, and feelings that
framework for understanding their own symp- are painful and distressing. However, while the
toms and to help them comprehend the treat- strategy of avoiding painful experiences works in
the short-run, it actually prolongs the post-trauma
ment rationale. Education about reactions to reactions and prevents you from getting over your
trauma includes information about PTSD trauma-related difficulties. (The therapist may
symptoms: the nature of fear and anxiety in want to elicit examples of the client's avoidance
response to triggers and cues, re-experiencing based on previous discussion of common reac-
the trauma, concentration problems, feeling tions.)
overly alert and on guard, avoidance of thoughts When you confront the painful experiences,
and feelings as well as reminders of the trauma, rather than avoid them, you will have the oppor-
emotional numbing, and anger. In this context tunity to process the traumatic experience. For
some related difficulties are discussed, including example, if you avoid assault-related situations
sadness about losses related to the trauma, that are objectively safe, you do not give yourself
the opportunity to get used to being in these
feeling out of control or crazy, negative self- situations. Unless you confront the situations,
image and ideas of incompetence, lack of trust in you may continue to believe that they are danger-
others and thoughts about the whole world or all ous and that your anxiety in these situations will
people being dangerous, relationship problems, remain indefinitely. However, if you confront these
sexual dysfunction or fears (usually following situations you will find out that they are not
sexual assault), and a rekindling of emotion actually dangerous and that your anxiety will
related to prior traumatic experiences. The diminish with repeated, prolonged confrontations.
education component is best delivered in an As a result of this process your symptoms will
interactive, collaborative style, providing the decline. The same is true for painful memories. For
patient with the opportunity to discuss his or her this reason we will ask you to relive repeatedly in
your imagination the assault and to confront
own symptoms and disturbing thoughts. relatively safe situations that you are now avoiding.
Today we are going to concentrate on your
6.22.7.2.4 In vivo exposure tendency to avoid situations and people that are
related to the trauma. In order to help you stop
A crucial component of exposure therapy is avoiding situations and people that were once
its rationale. In exposure therapy the therapist is enjoyable or important to you, we are going to
asking the patients to abandon their avoidance work together to make a list of situations that you
strategies used to manage their symptoms and have been avoiding since the assault. I call this list
instead to engage in imagery and in activities ªthe hierarchy.º I also want to find out from you
that are likely to cause some emotional distress how much distress or discomfort these situations
would cause you if you weren't avoiding them.
in the beginning. Understanding the rationale Therefore I will teach you a method to indicate
for this therapy that ªasks them to sufferº is your level of distress. Of course we will not ask you
essential for enlisting the patient's motivation. to confront unsafe situations. The goal is not to
In vivo exposure aims at reducing the anxiety help you view dangerous situations as safe, but
that patients with PTSD experience when they rather to help you stop avoiding situations that are
confront trauma reminders, and thereby return realistically quite safe. (Foa & Rothbaum, 1998)
After explaining the rationale, the therapist In each session, in vivo homework assign-
and patient construct a hierarchy of feared ments are reviewed to gauge progress and to
situations, listing all the situations or objects make modifications if the patient has difficulty.
that the patient either avoids or endures with Avoidance of homework is gently confronted
intense anxiety. The hierarchy may include and the rationale reviewed if necessary. New
situations that are directly related to the trauma assignments are explicitly planned with the
(e.g., being in the place where the trauma patient each session, and some discussion of
occurred), or situations that have come to logistical constraints, anticipated problems, and
evoke anxiety through generalization (e.g., alternate plans are helpful. Of course, some in
sleeping with lights off). A list of about 10 to vivo exposure may also be conducted in session
12 items is constructed and the therapist (e.g., looking at picture of the assailant) with the
describes the ªsubjective units of distressº therapist's guidance.
(SUDs) scale. The SUDs scale is anchored
individually for each patient, so that a 0
6.22.7.2.5 Imaginal exposure
indicates the most calm and relaxed that the
patient has ever felt (e.g., lying on the beach); As described earlier, the first step in exposure
and a 100 indicates the most fearful or dis- treatment is explaining the rationale for the
tressed the patient has ever been (e.g., during the procedure. The following is an example of the
trauma). The therapist then elicits SUDs ratings rationale being explained to a patient:
for each of the situations on the hierarchy,
indicating the level of distress expected when Today we are going to spend most of the session
confronting that situation. For example, Bon- having you relive the memory of your assault in
nie is a 37-year-old African-American woman your imagination. It is not easy to understand and
who was raped by a male acquaintance in a make sense of traumatic experiences. When you
think about the rape, or you are reminded of it,
friend's home. During the information gather- you may experience extreme anxiety and other
ing, she reported fear that had generalized to negative feelings such as shame or anger. The
being alone in many public situations. Her in assault was a very frightening and distressing
vivo exposure hierarchy follows: experience, so you tend to push away or avoid
the painful memories. You may tell yourself,
50 sleeping with the door closed and cur- ªDon't think about it; time heals all woundsº
tains closed or, ªI just have to forget about it.º Other people
often advise you to use these same tactics. Also,
50 taking the bus alone in the early evening
your friends, family, and partner may feel un-
60 going to sister's house (near assault) comfortable hearing about the assault, and this
60 wearing a skirt on the bus in the early may influence you not to talk about it. But, as you
evening have already discovered, no matter how hard you
try to push away thoughts about the assault the
75 sitting on a bench in a mall or shopping experience comes back to haunt you through
center nightmares, flashbacks, phobias, and distressing
75 taking a walk alone (daytime) thoughts and feelings. These symptoms signal us
75 walking by house where assault occurred that your assault is still ªunfinished business.º In
with friend this treatment our goal is to help you process the
memories connected with the assault by having
100 sitting in park alone (daytime) you remember them for an extended period of
100 looking at pictures of assailant time. Staying with these memories, rather than
100 sitting on steps of building where assault running away from them, will help decrease the
anxiety and fear that are associated with them. It is
occurred with friend
quite natural to want to avoid painful experiences
such as memories, feelings, and situations that
After the hierarchy is constructed, specific remind you of the assault. However, as we already
instructions about how to implement exposure discussed, the more you avoid dealing with the
exercises between sessions are given: memories, the more they disturb your life.
What we are going to do today is to begin
When you are practicing in the mall, for example, helping you process the memories associated with
you may initially experience anxiety symptoms, your assault. The goal of imaginal exposure as well
such as your heart beating rapidly, your palms as in vivo exposure is to enable you to have
sweating, feeling faint; you may want to leave the thoughts about the rape, talk about it, or see
situation immediately. But in order to get over the triggers associated with it without experiencing
fear it is important that you remain in the situation intense anxiety that disrupts your life. This part of
until your anxiety decreases. Once your anxiety the program includes having you confront situa-
has decreased at least 50%, then you can stop the tions and memories that generate both anxiety and
exposure and resume other activities. (Foa & an urge to avoid. Gradually, the memories will
Rothbaum, 1998) become less painful. You will get used to them.
Remember, we call this ªhabituation.º Before we indicates panic-level anxiety. Please answer
begin, do you have any questions about anything quickly and don't leave the image. Do you have
that I have said? any questions before we start? The rating should
Repeated reliving of the trauma will also help indicate how anxious you are at the time I ask,
you in other ways. It will teach you that remem- sitting here in my office, not how you felt during
bering is not re-experiencing the trauma. In other the assault. (Foa & Rothbaum, 1998)
words, it will help you discriminate between
remembering the trauma and being traumatized The therapist may probe for more informa-
again. There is no danger in remembering and
tion if the patient does not provide enough
therefore there is no good reason to become
overwhelmed with anxiety every time that you detail. The reliving exercise is maintained con-
think about the rape. Also repeated reliving will tinuously for 45±60 minutes, without discussion
teach you that you are not going to lose control or or interruptions, and is tape-recorded. If re-
go crazy if you engage with the traumatic memory. counting the entire trauma takes less than the
On the contrary, through repeated reliving of the allotted time, the therapist asks the patient to
rape you are going to gain control over your repeat it over again, until the full time is
memories instead of them having control over you. completed. Thus, several repetitions of the
And finally, engaging with the traumatic mem- trauma may occur in each session. Ideally,
ory repeatedly will allow you to differentiate reliving should continue until some reduction
between the traumatic event and other events that
in anxiety takes place, but it is sometimes
are similar but not dangerous. For example, now
you are afraid of all bald men because you were necessary to end the exercise without reduction
raped by a bald man. By repeated reliving of the in SUDs. In the first few sessions, reliving
rape you will realize that ªbaldnessº itself is not should focus on the entire trauma, but in
dangerous. (Foa & Rothbaum, 1998) successive sessions, the therapist and patient
select the most distressing parts, as indicated by
After explaining the rationale, the therapist high SUDs levels, as the focus of the reliving.
explains the method for prolonged imaginal We call these parts ªhot spotsº and they usually
exposure or reliving of the traumatic experi- represent the most distressing moments during
ence. The patient is asked to relive the trauma the trauma. The entire session can be focused on
vividly by describing it in the present tense, with one or two hot spots. Once these hot spots are
eyes closed. Patients are instructed to include in being processed and habituation occurs, the
the trauma recounting details of the physical distress during the remaining parts of the
environment, their actions; others' actions; their trauma narrative usually diminishes. We advise
thoughts and feelings; and bodily sensations that towards the end of treatment the entire
that had occurred during the trauma. Because trauma be relived again so that any newly
of the findings that emotional engagement emerging hot spots can be addressed before
enhances treatment efficacy, the therapist em- therapy is completed.
phasizes the importance of reliving the emo- The patient takes home the audiotape of the
tions that were experienced at the time of the reliving exercise, and is instructed to listen to it
trauma. An example of the instructions is as daily while imagining the trauma as vividly as
follows: possible. At the end of each reliving session, the
therapist and patient discuss changes in the
I'm going to ask you to recall the memories of the reliving experience within and between sessions,
assault. It is best for you to close your eyes so you and the therapist reinforces the patient's ability
won't be distracted and so that you can envision to confront such painful information without
these events in your mind's eye. I will ask you to losing control or going crazy.
recall these painful memories as vividly as possible.
We call this ªreliving.º I don't want you to tell a
story about the assault in the past tense. What I
would like you to do is describe the assault in the 6.22.7.3 Indications and Contra-indications
present tense, as if it were happening now, right
here. I'd like you to close your eyes and tell me As noted earlier, often in the beginning of
what happened during the assault in as much detail exposure treatment, the patient experiences an
as you remember. increase in anxiety owing to the confrontation
We will work on this together. If you start to with trauma reminders. Because of this initial
feel too uncomfortable and want to run away or increase in anxiety, patients should be relatively
avoid it by leaving the image, I will help you to
stay with it. We will audiotape the narrative so
stable prior to the beginning of therapy. Thus,
you can take the tape home and listen to it for active psychosis, alcohol or drug dependence, or
homework. From time to time, while you are self-injurious behavior should be addressed
reliving the assault, I will ask you for your anxiety prior to implementing exposure therapy. In
level on the 0 to 100 SUDS scale, in which 0 addition, there is some indication that exposure
indicates no anxiety or discomfort and 100 to an event about which the patient feels intense
guilt or shame, rather than fear, is contra- 6.22.7.3.2 Emotional Numbing

indicated, since imaginal exposure in such cases
Numbing of emotions, such as anger, is part
can accentuate guilt and shame (Pitman et al.,
of the definition of PTSD. Numbing is usually
1991).
defined as including several symptoms that
Other factors that require attention may not
constitute part of the avoidance cluster in
become apparent until exposure is initiated.
PTSD: disconnection or detachment from
These include severe anger, overwhelming
others, blunted emotional responsiveness or
anxiety, and emotional numbing (see Jaycox
expression, and lack of enjoyment in activities
& Foa, 1996; Jaycox, Zoellner, & Foa, 1997).
(e.g. Foa & Riggs, 1993; Foa, Riggs, &
Gershuny, 1995; Litz, 1993). Foa and Riggs
noted that the inclusion of numbing with
6.22.7.3.1 Anger effortful avoidance symptoms reflects the view
that these symptoms are motivated and main-
Anger is a natural response to a traumatic
tained by their capacity to reduce distress. It
event. Often there is an identifiable party that
follows that direct confrontation with feared
can be blamed for the trauma (e.g., the
stimuli will exacerbate numbing in patients who
manufacturer of faulty equipment, the assai-
use it as a coping strategy. However, increased
lant), and anger towards these parties appears
numbing would be expected to obstruct emo-
to be justified. Even when the blame cannot be
tional processing since it would hinder fear
clearly ascribed to another, as in some cases of
activation, thereby decreasing the effect of
natural disaster, trauma victims often experi-
treatment. One way to overcome the obstacle
ence a basic sense of injustice (e.g., ªWhy me?º).
presented by numbing during the exposure
Not surprisingly, then, anger is one of the
exercise is to remind the patient of the rationale
defining symptoms of PTSD.
for reliving. The therapist is also advised to
While some anger is a frequent feature of the
probe for details, thoughts, and feelings during
PTSD clinical picture, studies suggest that anger
the imaginal exposure.
may have a role in the formation or main-
tenance of chronic post-trauma disturbances.
6.22.7.3.3 Overwhelming anxiety
For example, Riggs et al. (1992) found that
female victims of a recent crime who reported Although a rare occurence, patients may
higher anger within two weeks of the assault, become so engaged in the reliving exercise that
also reported higher PTSD symptom scores one they experience the traumatic memory as if the
month later. The authors hypothesized that trauma is actually reoccuring. Consequently,
intense anger impedes the natural recovery the patient experiences the same overwhelming
process by interfering with activation of the fear anxiety and lack of control as he or she did
associated with the trauma, thereby obstructing during the trauma. This flashback usually
emotional processing. happens when the patient fails to incorporate
During treatment, intense anger appears to into the traumatic memory the information that
impede improvement in therapy by hindering he or she is in a safe place, that is, in the
emotional engagement. Facial fear expressions therapist's office. The therapist can take
during the first reliving of rape memory during measures to remind the patient that he or she
therapy predicted improvement following ex- is remembering the trauma, not re-experiencing
posure therapy and were inversely related to it. For example, the therapist can instruct the
self-reported anger prior to treatment (Foa, patient to relive the trauma with eyes open
Riggs, Massie, & Yarczower, 1995). Moreover, rather than closed, or can insert additional
anger at pretreatment was negatively correlated encouraging and reassuring comments during
with improvement. The latter result was the procedure.
replicated in a larger sample (Jaycox, Perry, In summary, the therapist should be attentive
Freshman, Stafford, & Foa, 1995). to these obstacles to exposure therapy, and
In contrast to severe and constant anger, should modify procedures, when needed, to
clinical observations suggest that moderate overcome them (Jaycox & Foa, 1996). In
episodic anger and irritability do not seem to addition to modification of the exposure
impede improvement in therapy. That is, a techniques, the therapist may wish to consider
certain degree of increase in anger is expected as alternative techniques, such as relaxation train-
anxiety increases during the initial stage of ing to address overwhelming anxiety, or
therapy, and this anger usually dissipates as cognitive restructuring to address anger and
arousal decreases. Thus, the therapist is advised guilt. These techniques are clearly helpful for
to contract with the patients to delay addressing trauma victims, as reviewed earlier, and can
anger-related issues until other emotions such as therefore be used to augment or replace
fear have been processed. exposure techniques in difficult cases.
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6.23
Psychoses: The Management of
Severe and Enduring Mental
Illness
GEOFF SHEPHERD
Health Advisory Service (HAS 2000), London, UK

6.23.2 DEFINING SEVERE AND ENDURING MENTAL ILLNESS 520
6.23.3 A PSYCHOLOGICAL FORMULATION 520
6.23.4 CHANGES IN THE ORGANIZATION OF MENTAL HEALTH SERVICES 523
6.23.5 SOCIAL AND PSYCHOLOGICAL DEFICITS 526
6.23.6 MODELS OF SERVICE DELIVERY 527
6.23.7 EFFECTIVENESS AND EFFICIENCY 530
6.23.8 METHODOLOGICAL PROBLEMS 532
6.23.9 DEVELOPING A ªUSER-LEDº SERVICE 533
6.23.10 STAFF TRAINING 536
6.23.1 INTRODUCTION managing chronic disability, with particular

emphasis on the importance of social outcomes,
The effective management of people with which form the core of modern concepts of
severe and enduring mental illness poses a mental health rehabilitation and which mark
number of complex psychological, social, and out the care of severe and long-term mental
economic problems. It begins with the applica- illness from more straightforward, ªtreatment
tion of a range of therapeutic interventionsÐ orientedº models. In this chapter we will focus
drugs, cognitive-behavioral therapy (CBT), specifically on the contribution of clinical
ªExpressed Emotion (EE) basedº family ther- psychology to this process.
apy, etc.Ðall aimed at addressing treatable Rehabilitation remains one of the most poorly
symptoms, but goes on to include ªmanage- understood areas of mental health. Tradition-
mentº interventions aimed at helping the ally, it has been synonymous with improving the
individual make a positive psychological ad- functioning of long-stay patients in institutions
justment to their difficulties and in facilitating so that they can move out of hospital and live
their social reintegration. It is this dimension of independently in the community, but this is now
519
520 Psychoses: The Management of Severe and Enduring Mental Illness
no longer of much relevance. As the locus of care duration of admissions); presence of disability
for most people with severe and enduring mental (long-term difficulties with social functioning
health problems has shifted from hospital to and adaptation); availability of formal and
community, so our ideas about their long-term informal support; and degree of risk to self or
management has also changed to reflect a much others. The typical criteria used are set out in
more dynamic view of the interaction between Table 1.
the psychiatrically disabled person and his/her The criteria in Table 1 highlight the issue of
social environment. Rehabilitation has become ªcomorbidityº in defining ªsevere and enduring
much more than a set of techniques aimed at a mental illness.º It is not just that these
single ªend pointº: it is a ªphilosophy,º a way of individuals may be suffering from the active
looking at the psychological and social problems symptoms of major mental illness (schizophre-
of people with severe and long-term mental nia, bipolar disorder), they also have a range of
health difficulties in their social context. It also social and occupational problems (poor or
provides a framework in which the social/ unstable housing, poor work records, lack of
environmental dimension has as much place social support) and may pose periodic risks to
as the biological and in which the management their own safety and/or those around them. It is
of ªchronicº disabilities is just as important as this combination of problems and needs which
the treatment of symptoms. These ideas form the makes this population particularly difficult to
conceptual framework for this chapter. care forÐand often particularly difficult to
But how can we provide operational defini- engage in conventional services. Thus, from a
tions for ªsevere and long-term mental illnessº? clinical psychology point of view, it may seem
How can we produce a psychological formula- difficult to know where to ªstart.º They have so
tion for the management of severe and long-term many problems, and there are so many
mental illness which links together biological, possibilities in terms of intervention, that the
psychological, and social influences? What are difficulty is in selecting the most potentially
the options in terms of delivering a service to effective strategy (and, as we shall see later, this
people with these kinds of problems and can we may not always be a strictly ªpsychologicalº
be confident that they will meet their needs? intervention). Nevertheless, the skills of a
What do we know about the effectiveness of clinical psychologist are highly relevant when
different models of service delivery and what are it comes to assessing needs for care, formulating
the methodological limitations of this evidence? care packages, and delivering effective inter-
How can we go about effectively involving users ventions.
in the planning and development of services and Notwithstanding the difficulties, such a list of
what implications does this have for staff and defining criteria also give those in a local service
staff training? These are the specific questions we a useful basis for defining those patients in their
need to address. Let us begin with the question of locality who have the greatest needs for
definition. complex, long-term, management programs
and who may therefore form the target for
specialist community teams. These individuals
6.23.2 DEFINING SEVERE AND are actually already likely to be known to a
ENDURING MENTAL ILLNESS variety of local agencies (e.g., inpatient teams,
primary health care, police, accident and
As community-based services for the care of emergency services, etc.) and it is often useful
people with severe and enduring mental illness to begin by cross-checking the list of names with
have begun to develop, so it has become each of the agencies. A local ªcase registerº can
increasingly clear that we need to define the then be compiled which may be used for
ªseverely mentally illº in order to discriminate subsequent planning and monitoring of the
them from the majority of those using main- service (for an example of this approach in
stream mental health services. These questions action, see Audit Commission, 1994, p.55).
of definition have real practical significance as,
without clear definitions, priorities cannot be
set and scarce resources cannot be targeted to 6.23.3 A PSYCHOLOGICAL
those in greatest need. FORMULATION
Attempts to define severe and persistent
mental illness have generally relied on multi- Having operationally defined severe and
dimensional criteria (Bachrach, 1988; Powell & enduring mental illness we then need a
Slade, 1996; Schinnar, Rothbard, Kanter, & psychological formulation which will help us
Jung, 1990). These usually employ a combina- organize our thinking and bring together
tion of diagnosis (usually major psychosis); information in a way that has both theoretical
indices of service contact (frequency and and practical implications for the management
A Psychological Formulation 521
Table 1 Criteria for defining people with severe and enduring mental illness.
A typical ªseverely mentally illº person might be expected to have:

(i) diagnosis of schizophrenia or major affective psychosis
and
(ii) at least two admissions in last year or six months continually in hospital in the last three years
and
(iii) significant problems functioning in at least two of the following areas:
basic literacy and numeracy
self-care
financial support (including money management).
housing (poor quality or unstable).
lack of social supports
lack of occupation/employment
difficulties with close personal relationships (family, etc.).
In addition, they are likely to show:

(i) poor compliance with prescribed medication
(ii) some degree of drug/alcohol abuse
(iii) difficulties in engaging in follow-up and aftercare
(iv) frequent crises and re-admissions
(v) significant history of self-harm, self-neglect, or harm to others
of care. The classic formulation, enshrined in proportionate to either the degree of impairment
the World Health Organization (WHO) classi- or the level of disability. Thus, a person may be
fication of impairment, disability, and handicap, symptomatically quite well recovered, with little
is derived from the pioneering work of the residual disability, but still very handicapped
English social psychiatrist John Wing (Wing, because of the reactions of those around him/
1978). herÐfriends, employers, neighbors, etc. Again,
Impairment refers to disturbances in function more will be said about the independence of
at the level of organ or bodily system. For symptoms, functioning, and social adjustment in
example, in schizophrenia brain functioning the following paragraphs.
appears to be impaired in relation to neuro- Although it is sometimes difficult to be sure in
transmission in dopaminergic pathways and this a given case how much a person's problems are
gives rise to the primary symptoms such as related to the underlying impairment, how
hallucinations, thought disorder, etc. Disability much is disability based on an adverse personal
refers to the effects of primary impairment on the reaction, and how much is due to social
person's ability to perform a range of necessary handicaps, nevertheless this conceptualization
social tasks and roles, for example, to shop, to provides a useful heuristic to help us think
cook, to work, to keep oneself reasonably clean about the design and implementation of multi-
and tidy, to establish and maintain relationships, faceted interventionsÐbiological, psychologi-
etc. A characteristic of disabilities is that they are cal, socialÐwhich will separately address these
long term and persist after symptoms have been different areas of need.
treated and must therefore be regarded as The distinction between symptoms and
semipermanent difficulties in functioning. Ad- functioning was first clearly demonstrated in
verse personal reactions to illness (loss of the classic studies on the course and outcome of
confidence, denial, loss of motivation) are often schizophrenia (Strauss & Carpenter, 1974, 1977;
also regarded as disabilities because their effects Strauss, Klorman, & Kokes, 1977). They
may be enduring. A person may thus be showed that each outcome ªdomainºÐ
ªdisabledº by their illness without it necessarily symptoms, social functioning, workÐwas rela-
having a direct or long-lasting effect on their tively independent of each other. This is
cognitive or intellectual ability simply through analogous to the ªdesynchronyº observed
its impact on their self-confidence and self- between different outcomes in other kinds of
esteem. The importance of these adverse mental health problems (e.g., fear and anxiety,
personal reactions and their implications for see Rachman & Hodgson, 1974) and has
models of management will be addressed in more important implications for both treatment
detail later. Handicap then refers to the social and management. For example, it implies that
consequences of impairments and disabilities, changes in symptoms may not always produce
for example, unstable housing, poor work generalized improvements in functioning. Thus,
record, loss of social supports, stigma, etc. the person may show positive improvements in
Again, the degree of handicap may not be symptoms, while remaining socially quite
disabled. Indeed, this is quite common (De and the difficulties that they cause both for the
Jong, Giel, Sloof, & Wiersma, 1986). Conver- patients and for the staff and other carers who
sely, it may be possible for an individual to are looking after them.
function quite well socially and vocationally In stressing the importance of disability, we
while still experiencing severe symptoms. This is should also emphasize that psychiatric disabil-
probably less common, but certainly not rare. ities are not fixed and immutable in the same way
Interventions therefore need to be targeted to as physical disabilities. In physical rehabilita-
producing specific changes in functioning and it tion, the problems of adaptation may be solved
cannot be assumed that if symptoms are treated by the provision of a range of physical supports
(whether physically or psychologically) then (e.g., wheelchairs, ramps, large print, induction
this will automatically have a generalized effect hearing loops, etc.). By contrast, the problems of
on behavior. the psychiatrically disabled person center
By definition, ªenduring mental illnessº is around ªsocial accessº (e.g., to ordinary hous-
long-term and a psychological model of reha- ing, ordinary jobs, nonsegregated leisure activ-
bilitation therefore has one other cardinal ities, etc.) and these depend on the provision of
feature: it is concerned with people who may social supportsÐfamilies, professionals, non-
not ªget better.º Rehabilitation asks, ªHow can professional carers, etc.Ðand social attitudes
we help people manage despite their disabil- (e.g., of friends, family, employers, etc.). Long-
ities?º It says, ªBy all means try and treat term social adaptation will be largely determined
people, but if they don't respond then how can by the stability of these supports and, since they
we help them make the best adaptation possible, are very much dependent on individuals, they are
given the fact that they have difficulties in inherently fragile. Social tolerances may also
functioning which are, in the current state of change: employment opportunities may dimin-
knowledge, essentially untreatable?º ish (or increase), people become tired, move on,
This concept of psychological ªdisabilityº get promoted, lose hope, die, etc. The pattern of
(i.e., untreatable symptomatology) still creates psychiatric disabilities therefore can changeÐ
problems for many mental health professionals. both for the better and the worseÐand
They do not like to admit the existence of rehabilitation services have continually to
problems which they cannot do anything about monitor and adjust the level of their interven-
and managing disabilities seems an altogether tions, offering more, or less, support as the
less glamorousÐand lower statusÐactivity person's social circumstances change. Good
than treatment and ªcure.º In dealing with rehabilitation is about the quality of this
people with severe and enduring problems, ªcontinuing careº and how to achieve this
many professionals therefore find themselves in through effective teamwork, training, and
a state of psychological ªdissonance,º that is, leadership are all topics to which we shall return
there is a discrepancy between their expecta- to later.
tions of themselves and what they find they can This formulation of the dynamic nature of the
achieve with their patients. There is then a relationship between the individual's function-
temptation to resolve this conflict either by ing and the social environment lies at the heart
devaluing the patient (i.e., ªthey are untreatable of our current attempts to provide ªcommunity
and therefore not worthy of further time and care.º Psychiatrically disabled persons living in
resourcesº) or by feeling personally devalued (ªI the community are struggling to maintain their
am ineffective and therefore don't have any- social adaptation, while being constantly ex-
thing to offer this personº). Either way, staff posed to a changing (and therefore stressful)
may wish to avoid or withdraw from those with social environment. In these circumstances, it is
the most severe problems and seek out more not surprising that their adaptation breaks
therapeutically ªpromisingº clients. This is down from time to time and they need to be
compounded by a culture in which health ªrerehabilitated.º This is not ªfailureº: it is the
services are very ªoutcomeº and ªthroughputº inevitable outcome of change, life events, and
orientedÐoften for simple, financial reasons. limited coping capacities. But it does imply a
Long-term, intractable difficulties are therefore very specific approach to the organization of
unwelcome news for both clinicians and services and to the training and support of staff
managers alike and the challenge of rehabilita- and family carers.
tion services is how to think creatively about How the organization of mental health
services which will promote social functioning services for people with severe and long-term
and facilitate social reintegration while, at the mental health problems has changed over the
same time, accepting the possibility of very last 40 years and what implications this has for
small and slow changes over time. This can only the context in which professionals, patients, and
be based on a sophisticated psychological their families now have to operate will now be
understanding of the nature of the problems discussed.
Changes in the Organization of Mental Health Services 523
6.23.4 CHANGES IN THE simply extolling the need for greater coopera-
ORGANIZATION OF MENTAL tion does not solve the bureaucratic and
HEALTH SERVICES organizational problems of getting large agen-
cies, with very different cultures, to understand
Most countries have been struggling to move one another's aims and priorities. These are
away from an organization of mental health essentially social and psychological problems
services that depends heavily on residential and require psychological solutions.
provisions sited in large, old, psychiatric The model of a single agency provider has
hospitals. This change is partly motivated by actually been subject to experimental evaluation
a beliefÐnow supported by considerable in the US through the Robert Wood Johnson
evidenceÐthat most people with serious and Foundation program (Goldman, Morrisey, &
enduring mental health problems prefer to live Ridgely, 1994). This ambitious project aimed to
and function better in various kinds of sheltered create unified mental health authorities across
and supported settings in the community where eight US cities. In organizational terms it
they can have access to the same range of generally succeeded very well, however, it failed
activities and social supports that are available to deliver much in the way of improved health
to every other citizen. and social outcomes for patients, mainly
The movement towards the community has because insufficient attention was paid to
proceeded at different rates in different coun- changing the practice of professionals through
tries. Some (e.g., The Netherlands) have man- new training initiatives, staff development, and
aged to maintain a very good standard of care in support (Lehman, Postrado, Roth, McNary, &
their hospitals, while at the same time vigorously Goldman, 1994; Morrisey et al., 1994). The
developing community alternatives. OthersÐ lesson is clear: organizational change is not
and here the UK is a good exampleÐhave had enough. If services are going to improve we
more difficulty in ensuring adequate access to therefore need to think about how to change the
inpatient provision (both short- and long-term) behavior of staff as well as how to change
as the overall number of long-stay beds has organizational structures.
reduced. These changes have confirmed the However, in both the US and the UK there
warnings of scholars like Leona Bachrach who have been substantial reductions in long-stay
reminded us more than 20 years ago that the beds in mental hospitals over the past 40±50
traditional mental hospital was a complex years (Bachrach, 1997). In the US there has been
organization, fulfilling a number of medical, an 86% reduction in the number of beds
psychological, and social needs and that, if we provided in state hospitals over a period of 40
had ambitions to manage without it, we would years (560 000 in 1955 to 77 000 in 1995). In the
need to develop an equally complex range of UK, there has been a similar dramatic reduction
services in the community (Bachrach, 1976). (from 155 000 in 1955 to less than 25 000 today).
All countries have experienced some difficul- What effects have these changes had on the
ties in ensuring that there is an adequate range overall service ªsystemsº and on the lives of
of housing, occupation, social, psychological, individual patients and their families?
and medical support for all those who need it. At the outset, it is important to distinguish
Part of the reasons for this are clearly financial, between those ªoldº long-stay patients who have
but part are also related to the difficulties of been most directly affected by the reductions in
interagency cooperation implied by such an mental hospital beds and the next generation of
agenda (Mechanic & Aiken, 1987). To recreate potentially ªnewº long-term patients who would
comprehensive community services for the most perhaps have gone into long-stay beds in the
severely psychiatrically disabled demands a past, but for whom this is now no longer an
high level of cooperation between different option. Many of the ªoldº long-stay patients
providersÐhealth, social services, housing have simply swapped one form of institutional
agencies, work and occupational programs, care for another (so-called ªtransinstitutionali-
primary care teams, etc. These agencies are all zationº). However, the quality of their lives may
organized and managed differently, with dif- still have improved, providing the new accom-
ferent priorities, different planning cycles, and modation is at least superior to a large,
different funding streams. It is therefore not impersonal, and old-fashioned psychiatric hos-
surprising that effective interagency coopera- pital. But the ªnewº long-term patients: young,
tion is difficult to achieve and that there have with major mental illness, severe symptoms,
been repeated calls for health and social care often complicated by drug and/or alcohol
agencies to work more closely together. This has misuse, sometimes with a history of violence
certainly been the thrust of successive planning or self-harm, have fared less well. They may have
guidance from the UK Department of Health ended up in acute inpatient units, often on
(e.g., Department of Health, 1995). However, general hospital sites, and become ªnewº long
stay inpatients (Lelliot, Wing, & Clifford, 1994; al observation measure. Residents were also
Mann & Cree, 1976). Alternatively, they may be interviewed individually to determine their
caught in the ªrevolving doorº of acute admis- quality of life and satisfaction with their current
sion, followed by premature discharge to living situation.
inadequate support in the community, leading The results showed that the most disabled
to rapid relapse, and re-admission. Most residents were concentrated in hospital, which
worrying of all, they may have dropped out of generally offered the poorest quality of care and
formal mental health services altogether and be the most ªinstitutionalisedº staff. Not surpris-
existing on the margins of society, in poor or ingly, patients in hospital were much less
unstable housing, on the street, or in prison. satisfied and complained of lack of privacy,
They are the most obvious casualties of these autonomy, and independence. In comparison
changes in the patterns of service provision. Let with the large differences between hospital and
us now examine the fate of these two groups in community, the differences between community
more detail. providers were small. Although, as in hospital,
As indicated, the quality of life for older the personality and leadership style of the
patients who have been reprovided for in the project manager appeared to be very important.
community as part of a systematic reduction in Where project leaders encouraged a positive
beds in old, psychiatric institutions may or may and respectful attitude towards residents, other
not have been enhanced depending on the aspects of the quality of care appeared to be
quality of their new accommodation. It is good. Where they were more careless or
difficult to generalize because so much depends neglectful, then this was also usually reflected
on local conditions, but the largest study of its in the overall running of the home. This study
kind in the UK (possibly in the world) of the was consistent with the findings of the TAPS
outcomes for patients moved from two large team in suggesting that for most of those
psychiatric hospitals in North LondonÐthe so- directly affected by reductions in long-stay beds,
called TAPS (Team for the Assessment of the quality of their care has improved and, with
Psychiatric Services) studyÐsuggested that it, their perceived quality of life. For them,
those who move into reasonably good-quality community care has been a success and certainly
residential care generally showed similar clinical has proved preferable to life in a traditional,
and symptomatic outcomes compared with psychiatric institution.
matched cohorts who remained in hospital, It is important to recognize that the reduction
had better social outcomes, enhanced social in hospital beds does not necessarily mean that
networks, showed decreased behavioral pro- there has been a reduction in the overall amount
blems and improved medication compliance, of residential provision. As the notion of
and were much happier with their living transinstitutionalisation implies, the system of
situation, compared with matched cohorts care may have changed in terms of who is
who remained in hospital (Leff, 1997). There providing residential accommodation, but the
was no evidence of increased death rates, absolute number of places may not have altered
suicide, crime, or vagrancy. The cost of care greatly. This is illustrated by Martin Knapp and
in the community was generally slightly less his colleagues, again in the TAPS study, who
than of continuing care in hospital, but showed showed that there has been a significant growth
significant increases with increasing levels of in provision managed by ªvoluntaryº and
disability (Beecham et al., 1997). ªindependent sectorº organizations. (These
A more detailed study by Shepherd, Muijen, are a mixture of private ªfor profitº and
Dean, and Cooney (1996) attempted to examine ªnot-for-profitº providers). In the UK, this
some of the variability in the quality of care in almost completely compensated for the loss of
residential provision for ex-long-stay patients in inpatient beds (Knapp, Beecham, & Hallam,
the community. They surveyed 20 residential 1997). However, the ªmixed economyº of care
homes in the London area, all of which had been does pose problems in terms of regulation and
established in connection with mental hospital the monitoring of standards and it is worth
closure programs. The homes were selected remembering that the public mental hospital
randomly to represent the range of current system was created precisely because of fears
providers (housing associations, local Social that a private system would be difficult to
Services departments, private-for-profit, etc.) regulate and inspect (Jones, 1972). Such
and were compared with a small sample of problems do not go away.
ªrehabilitationº wards from the local psychiatric Probably the most important effect of the
hospitals. Residents and staff were assessed reduction in mental hospital beds in the UK has
using a battery of standardized measures, the been the impact on the current acute services
organization and quality of care was examined, caused by the failure to develop adequate
and care was directly observed using a behavior- alternatives to long-stay inpatient provision.
Changes in the Organization of Mental Health Services 525
This is illustrated in another recent study in the new long-stay patients in general hospital based
UK by Shepherd, Beardsmoore, Moore, Hardy, acute units, compared with those based in
and Muijen (1997). They constructed a nation- mental hospitals, is consistent with the hypoth-
ally representative sample of acute psychiatric esis that these patients are accumulating in acute
units, stratified according to levels of local units because of a lack of suitable alternatives.
social deprivation. Information was then col- Those requiring higher levels of supervision in
lected regarding the numbers of available beds, the form of secure accommodation (for reasons
staffing levels, and ªactivityº (i.e., throughput). of violence) amounted to around 10%,
The range of local services, such as community although this proportion was higher (17%)
mental health teams, crisis services, and sup- among the new long-stay patients. The HoNOS
ported housing was also described. A census severity scores were consistent with the staff
was completed of all the patients resident on a judgments, thus validating the placement op-
given day and background data collected tions selected by the staff.
together with ratings of clinical and social These results therefore support the hypothesis
functioning using the ªHealth of the Nation that patients are now accumulating on acute
Outcome Scaleº (Wing, Curtis, & Beevor, admission wards who would previously have
1996). Staff were also asked to indicate whether been accommodated on long-stay wards, in
or not they judged that the individual still secure provisions, or in various community
required to remain on an acute inpatient ward alternatives. The resultant shortage of acute
and completed a standardized checklist cover- beds seems to be related to both social depriva-
ing the possible reasons preventing discharge or tion and lack of bed availability. However, it is
transfer to a more appropriate setting. clear that a simple expansion of acute beds would
The results provided information on over not effectively address the problem. If all the
2000 patients admitted on nearly 40 sites patients who are judged to be inappropriately
covering approximately half the population of placed on acute admission wards could be
England and Wales. Fifty-two percent were relocated, then the problem of overoccupancy
female; the mean age was 41 (s.d. = 15.07), 88% would effectively be solved. Acute units could
were White; and 30% were currently detained then get on with the task of looking after the
under a Section of the Mental Health Act. patients they are meant to be targeting (i.e., those
Seventy-four percent had a diagnosis of schizo- whose needs are for immediate treatment and
phrenia or mood disorder. Diagnoses of sub- symptom stabilization). But this does mean the
stance abuse, neurosis, and personality disorder creation of truly comprehensive community
accounted for another 6% each. The median services, with a spectrum of residential options
length of stay was 28.5 days, but 7% had current geared to different levels of need and different
lengths of stay greater than six months (i.e., kinds of problems. There are clearly consider-
would be classified as ªnewº long stay). Their able difficulties in achieving this, particularly in
prevalence was much higherÐalmost doubleÐ inner cities, with a background of poor housing,
in general hospital based acute units, compared high unemployment, and other social problems.
with those sited in mental hospitals (9% vs. Apart from new resources, the creation of
5%). There was a negative relationship between comprehensive community services which can
the number of available adult acute beds and look after the most disturbed (and disturbing)
bed occupancy and there was also a relationship individuals also implies a very considerable
between levels of social deprivation, acute bed change in public attitudes towards the care of
availability, and bed occupancy. Those services people with severe and enduring mental health
with low bed availability and high social problems. At the present timeÐat least in the
deprivation therefore had the highest bed UKÐattitudes could hardly be less favorable.
occupancy levels. The inadequate development of community
Despite these problems with overoccupancy, alternatives, combined with the reduction in
just over a one-quarter (27%) of current long-stay beds, has led to some highly publicized
inpatients were judged not to require continuing failures of community care in which members of
admission and this proportion was significantly the public have been injured, or even killed, by
larger among those with admissions of more people regarded as ªmentally ill.º The percep-
than six months. The most common reasons tion that community care has failed has been
preventing discharge were the nonavailability of reinforced by sensationalist press and media
various community and residential options, in coverage, although there is actually no evidence
particular the lack of suitable supported hous- that the rate of homicides committed by people
ing. As might be expected, a lack of specialized with a mental illness is actually increasing, nor
rehabilitation places was seen as a more that the care of those who committed these acts
important reason preventing discharge for the would have been improved if more psychiatric
new long-stay group. The higher prevalence of beds had been available. In reality, the problems
seem to have been not so much due to a shortage capped that it was difficult to see where they
of resources, but of a failure to coordinate might be placed.
resources effectively and to communicate be- A very similar pattern of results have been
tween different agencies (Ritchie, Dick, & obtained from comparable populations in the
Lingham, 1994). It is thus the organization of US. For example, in a classic paper Sheets,
services that has been deficient, not their basic Prevost, and Rehman (1982) hypothesized three
structures (or even, in many cases, the overall subgroups among the new, ªyoung chronics.º
level of resourcing). The first group they described as characterized
As this new group of very disturbed and very by ªlow energy/low demandº with long histories
difficult young people have begun to emerge, it of contact with services, passivity, low motiva-
has also become clear that traditional models of tion, poor personal hygiene, and treatment-
service delivery will simply not be effective with resistant symptomatology. They appeared
them. Many of these young people are very ªburnt out,º accepting of their status as
sensitive to stigma issues and are reluctant to ªchronicº patients, despite their relative youth.
engage with traditional services which they feel The second group was termed ªhigh energy/high
simply add to their sense of alienation and demandº and these individuals were character-
isolation. They want new forms of servicesÐ ized by low frustration tolerance, high geogra-
housing, work, etc.Ðwhich are not substan- phical mobility, rapidly fluctuating levels of
tially different from those available to normal functioning and symptoms, ªacting outº beha-
people. Furthermore, they want services deliv- vior, aggression, contact with the law, etc.
ered at the times and places most acceptable to 5>They were very demanding, uncooperative,
them, rather than those which are most and difficult to manage. Finally, there was a
convenient for the professionals. Such services ªhigh functioning/high aspirationº group, char-
have been slow to develop and, as a result, some acterized by relatively good premorbid history,
of these individuals have opted out of formal coming from the middle class, having high
mental health care, sometimes with tragic ambitions, but unable to realize them. They
consequences both for themselves and others. often also had significant problems with drug or
So, what can done to improve services for this alcohol abuse. This group were also rejecting of
group in the future? their status as chronic patients, but accepting of
help from mental health services insofar as it
would enable them to lead relatively normal,
6.23.5 SOCIAL AND PSYCHOLOGICAL unstigmatized lives.
DEFICITS Gudeman and Shore (1984) also described the
characteristics of patients in their service in
First, we must clearly understand the nature Boston who had proved very difficult to look
of their psychological and social deficits. In after in conventional community accommoda-
1994, the UK Royal College of Psychiatrists' tion. They consisted of a mixture of elderly,
research unit reported on a national audit of demented people with behavioral disturbance
new long-stay inpatientsÐthose who had been (20%), mentally retarded persons with conco-
in hospital continuously for more than six mitant psychiatric illness and aggressive beha-
months, but less than three years (Lelliot & vior (20%), people with acquired brain damage
Wing, 1994; Lelliot et al., 1994). Almost two- and loss of impulse control (10%), and two
thirds (62%) had a diagnosis of schizophrenia, groups of predominantly schizophrenic pa-
half had more than five previous admissions to tients, one with unremitting assaultive or
hospital, and just under one-third (29%) were suicidal behavior (17%) and the others who,
detained under a Section of the Mental Health while not being a frank danger to themselves or
Act (mostly for compulsory treatment). They others, showed such unacceptable social beha-
showed multiple disabilities, with a high pre- vior (e.g., disrobing in public, eating garbage,
valence of severe, treatment-resistant symptoms continually vomiting food at mealtimes) that
and a range of other behavioral problems they would not be tolerated in an ordinary
(violence, self-harm, extreme antisocial beha- community setting (33%). Similarly, Bigelow,
vior, etc.) which made them difficult to look Cutler, Moore, McComb, and Leung (1988)
after outside hospital. They tended to be socially studied a group nominated as ªhard to placeº by
unskilled, with poor work records, few family staff in a state hospital. Almost three-quarters
ties, and poor physical health. About one-third (70%) had a primary diagnosis of schizophrenia,
were judged to be capable of living in the often in association with drug and alcohol
community if highly supervised hostel place- problems and almost two-thirds (62%) showed
ments were available, about one-third were significant levels of violent and assaultive
deemed to require further treatment in hospital, behavior. They also note the high prevalence
and the remainder were so multiply handi- of poor self-care, leisure, and social skills.
Models of Service Delivery 527
Thus, a consistent picture emerges, across service therefore needs to evolve in order to fit
very different settings and local conditions, of the local conditions.
the psychological and social deficits found in At the extreme end of the housing spectrum
people who are difficult to place in traditional there are those individuals with severe and
services. First, there is a group of young men, enduring mental health problems who are
almost all of whom have a primary diagnosis of actually homeless, or in unstable, or very poor
schizophrenia, who show severe and intractable quality housing. The problem of severe mental
ªpositiveº and ªnegativeº symptoms and a illness among homeless populations has received
variety of behavioral problems. They may also considerable attention worldwide (Bachrach,
have concomitant drug or alcohol misuse. This 1992; Bhugra, 1996; Timms, 1993) yet there is
is the largest group and, depending on local still controversy concerning the link between
circumstances, is likely to account for between reductions in hospital beds and apparently
two-thirds and three-quarters of the total. increasing numbers of mentally ill people among
Second, there is a group of older persons, the homeless. Most of the evidence seems to
primarily female, who are more likely to have point to an indirect link, with other factorsÐ
treatment-resistant affective psychoses (de- particularly general housing, benefit, and un-
pressed type or rapid cycling bipolar conditions) employment policiesÐalso exerting a consider-
and who present a significant risk to themselves able influence. Thus, the typical mentally ill
and may show extreme self-neglect when they homeless person in the UK is actually young
are acutely depressed. They are likely to account (i.e., under 30 years), with some degree of alcohol
for a further 20%. Third, there is an hetero- or other drug abuse, and a range of social and
genous group, usually having organic brain occupational disabilities in addition to their
syndromes (acquired brain damage, presenile mental illness, but without a previous history of
dementia, low IQ, alcoholism, etc.) again, often long admissions to psychiatric hospitals (Craig,
with other associated behavioural problems, Bayliss, Klein, Manning, & Reader, 1995). Often
sometimes also showing comorbidity with they may have had a series of short admissions
psychosis. They usually account for about (i.e., ªrevolving doorº) but generally do not have
10%. What are the options for these groups the characteristics of an old long-stay patient
in terms of models of service delivery? who has been turned out of a mental hospital. In
terms of service provisions, apart from the
obvious need for stable, good-quality housing,
6.23.6 MODELS OF SERVICE DELIVERY the most successful management approaches
appear to be using specialist community teams,
The range of services necessary to meet this who practice an ªassertive outreachº model
complex combination of needs, in the absence of (Dixon, Krauss, Kernan, Lehman, & DeForge,
large numbers of beds in mental hospitals, have 1995). Breakey (1996) also notes four stages in
been well described in a number of strategy providing psychiatric services for the homeless:
documents published on both sides of the (i) engagement; (ii) provision of basic services;
Atlantic (Department of Health, 1994, 1997; (iii) transition towards mainstream services; and
Stroul, 1986). At the center of these systems lie (iv) integration into ordinary housing and work
various forms of sheltered and supported programs. We will have more to say about the
housing. work of these kinds of specialist community
It is something of a truism to state that teams later, suffice to say at this point that the
without adequate accommodation effective contribution of clinical psychology to all these
management of those with the most severe stages in terms of both assessment and manage-
and enduring mental health problems will not ment is very important.
be achievable, but nevertheless it bears repeat- As indicated, the goal of working with people
ing. What is difficult is to specify the precise with severe mental illness who are homeless is
levels of the different kinds of accommodation generally to try and get them into some kind of
that are required. Attempts have been made stable, sheltered, or supported housing. So, how
(e.g., Strathdee, Davies, Perry, & Thompson, can we judge the quality of care in such housing
1996; Wing, 1992) but any general guidelines provisions? The principles underlying good-
always require qualification depending on local quality care in supported housing have recently
circumstances. The greatest shortages are been described by Shepherd (1998a). First, each
usually regarding high-support housing of person must be regarded as an individual with a
various kinds, but the possibilities of substitut- unique set of needs and abilities. This is the
ing one kind of facility or service by another antithesis of the ªblock treatmentº which
(e.g., intensive support teams instead of high- characterized traditional institutional settings
support housing) make ªnormative planningº (Goffman, 1961). Nobody should be given care
difficult. Each location is different and each that he or she does not need and, conversely,
nobody should be denied help because of general (Grove, 1994; Pozner, Ng, Hammond, &
rules or expectations regarding levels of func- Shepherd, 1996). Just as in housing, one should
tioning or performance. Staff should make use of not expect everyone necessarily to ªprogressº
their everyday observations of residents in a through the system, acquiring more and more
variety of community settings (shops, public skills, and therefore requiring less and less
transport, eating houses, etc.) to make direct support. Some will and some won't: and it is
assessments of their skills and deficits. Residents important to allow individuals to settle at their
should be fully involved in the formulation of own ªlevel.º There must be opportunities to
their own care plans and these should be move on (e.g., toward open employment) but
reviewedÐtogether with staffÐat least weekly. also opportunities to stay if this is more
The aim should be to create an active, consistent with their abilities and aspirations.
information-rich, environment in which staff Users particularly value services which they
use their relationships with residents, in the see as having a positive image and as being well
context of collaboration over everyday activ- regarded by others (Dick & Shepherd, 1995). It
ities, to shape behavior. In general terms, there is thus insufficient that professionals regard a
should be an emphasis on practical tasks and particular work program as representing good
daily living skills and a deemphasis of pathology. practice. The crucial question is, ªDo users want
(This is not to say that symptoms or psycholo- to go?º If not, then it will fail to engage some of
gical distress should be ignored but, by defini- the most difficult, younger people with psy-
tion, these residents will have exhausted most chosis who actively reject conventional day and
conventional therapeutic approaches.) The work programs. Of course, not everyone will
crucial question is, ªTo what extent do their want to engage in work programs, however
symptoms interfere with their ability to func- attractive services try to make themÐthat's also
tion?º This emphasis on functioning rather than fine. But we cannot afford to alienate users by
symptoms gives a clear ªnormalizingº message offering services which essentially reflect the
to residents and contributes to the maintenance therapeutic interests and values of highly paid
of an ordinary household atmosphere. professionals, rather than what they say they
Finally, staff should be encouraged to moni- want. In this connection it is worth remember-
tor the quality of their interactions with ing the classic study of Linn, Coffey, Klett,
residents, as well as their quantity. Quality in Hogarty, and Lamb (1979) which showed that
this context means not only a respect for the the number of psychologists and other thera-
individual, but also a style of interaction that pists was inversely correlated with a good
conveys clear expectations about performance outcome in day programs supporting people
and tries to minimize criticism and censure. This with schizophrenia in the community. Modern,
may be characterized as a low EE style and relevant, high-status work activitiesÐ
follows from the recent evidence that high levels computing, silk screening, designing T-shirts,
of criticism and hostility expressed by nonfamily producing interesting looking booklets and
carers may also be detrimental, just as within newslettersÐcombined with loud music (and
certain dysfunctional families (Ball, Moore, & financial remuneration) may therefore be the
Kuipers, 1992; Moore, Kuipers, & Ball, 1992). In necessary ingredients to attract many of the
terms of staff support, there needs to be an target group. If this is what is needed to give
emphasis on consistency, continuity, teamwork, work programs a positive image, then this is
and communication. Maintaining a positive what must be provided.
therapeutic environment is probably the most The Clubhouse Model (Beard, Propst, &
difficult task of all, staff need to meet regularly Malamud, 1982) has also proved a very popular
and continually to have the opportunity to approach with some service users who are
review their work with each other and with seeking a more positive image from mental
senior colleagues. Teams are fragile and a lot of health day care programs. The principles of this
time and effort has to go into ªfeedingº them to model are set out in Table 2. As can be seen, the
keep them functioning at their highest level. clubhouse model emphasizes mutual coopera-
Next to accommodation, most service users tion and consensus between staff and members
place work and/or employment as their greatest in the development of the program and the
priority (Rogers, Pilgrim, & Lacey, 1993; importance of meaningful occupation both
Shepherd, Murray, & Muijen, 1995). In terms within and outside the clubhouse. It has proved
of developing a comprehensive service, the aim very popular, particularly in the US and, more
must again be to provide a range of work recently, also in the UK and other parts of
opportunitiesÐassessment and training, place- Europe (e.g., Sweden). However, it has not been
ment in open employment with support, without its detractors.
sheltered social firms and cooperative busi- For example, Transitional Employment Pla-
nesses, etc.Ðto cover the range of users' needs cements (TEPs) have been criticized because of
Models of Service Delivery 529
Table 2 The principles of the Clubhouse Model.
It is a club and, as in all clubs, it belongs to those who participate in it

Members and staff work together to design and implement the clubhouse program
The clubhouse believes in the value and dignity of meaningful work activities
All members are made to feel on a daily basis that their presence is expected and that their
attendance really makes a difference
There are never enough staff to run the program on their own: members' contribution is therefore
necessary for the success of the program
Members have an opportunity to experience Transitional Employment Placements (TEPs). These
offer fixed-term, part-time, entry-level work experience and may be used as stepping stone to paid
employment
Membership is for life and the clubhouse is open seven days a week, 365 days per year
Source: Beard et al. (1982).
the restrictions placed on entry-level positions. which provide specialized help and support in a
This is necessary because the model demands segregated form.
that any member or staff person can, in Regarding social support, evidence has
principle, cover any position. As a consequence, continued to accumulate that different indivi-
it means that TEPs tend to be limited to very duals have very different needs in terms of social
simple jobs and may therefore be unattractive to support and that these may vary significantly
those seeking re-entry into highly skilled or over time. For example, Cresswell, Kuipers, and
professional careers. The style of shared Power (1992) demonstrated how people with
decision-making between members and staff severe negative symptoms may have less need
has also been criticized as not being genuinely for close emotional support, but greater need
participative and therefore not really ªuser ledº for more practical kinds of help. This is
(Chamberlain, 1988). Whether this is fair consistent with other evidence regarding the
probably depends on the specific clubhouse limited needs of some very disabled patients for
concerned, but there is some evidence to suggest close emotional support (e.g., Mitchell & Birley,
that users do feel involved and empowered in 1983). In a classic paper, Brier and Strauss
clubhouses and that this contributes signifi- (1984) described systematic changes in social
cantly to their overall life satisfaction (Rosen- support needs as the people recovering from
field & Neese-Todd, 1993). psychotic episodes progressed from convales-
Perhaps the most serious criticism of club- cence in which reality testing, material help,
houses is that the intentional community created social approval, etc. were the priority, through
by the clubhouse culture, while being very to rebuilding in which the attention shifted to
attractive to some individuals, may not be motivation, reciprocal relations, and symptom
helpful to others in terms of their reintegration monitoring. These considerations have led
into mainstream social activities. There is clearly writers like Harris, Bergman, and Bachrach
a dilemma here: on the one hand, the clubhouse (1986) to stress the importance of ªindividua-
provides a sheltered setting which protects lized network planning,º that is, tailoring
vulnerable and disadvantaged people from the interventions much more closely to the indivi-
stresses of ordinary social contactÐasylum in dual's unique pattern of social needs.
the best sense of the word. On the other, an In the social support literature, there has also
asylum, however positive, may become difficult been a change from a preoccupation with the
to leave and therefore runs the risk of creating an size of social networks to an examination of the
unhelpful dependency. There is no satisfactory influence of other network variables, particu-
answer to this dilemma (and, of course, it occurs larly their composition and density (i.e., inter-
in other models than the clubhouse). Services connectedness). Thus, it has been known for
simply have to strive to strike a sensitive balance some time that social isolation tends to be
between shelter and independence and ensure associated with a higher risk of admission, but it
that they have clearly permeable boundaries so is now clear that repeated admission to hospital
that individuals do not become isolated and cut also affects the composition of the network.
off from normal social life. This is a fundamental Over time, friends and relatives are gradually
problem for all dedicated community services replaced by mental health professionals and
(housing, work programs, social programs, etc.) other service users (Holmes-Eber & Riger,
1990). This is not only likely to lead to lowered elements. However, there is often poor integra-
levels of satisfaction with social supports tion between hospital and community services
(Goering et al., 1992) but may also create and community teams may thus need to develop
networks which are relatively poor at providing ªassertive inreachº to the inpatient units, as well
help in a crisis, since they are diffuse and lack the as ªassertive outreachº to the community.
interconnectedness necessary to mobilize sup- So, what is the evidence for the effectiveness
port quickly in an emergency (Dozier, Harris, & of these different components of a comprehen-
Bergman, 1987). Improving communication sive community service?
(interconnectedness) within support networks
should therefore be one of the central goals for
specialist community teams. 6.23.7 EFFECTIVENESS AND
Specialist community teams are the glue that EFFICIENCY
keeps services together around individuals and
allows them to reach their potential while, at the There is a dearth of evidence regarding the
same time, ensuring that they receive sufficient effectiveness of different kinds of community
support. These teams were pioneered for the accommodation. As indicated earlier, most
severely mentally ill by Leonard Stein and his long-stay patients show lower levels of symp-
colleagues in Madison, Wisconsin (Test & Stein, toms (particularly negative symptoms), have
1978) and have now been operating successfully better social integration, and report higher
for more than 25 years (Thompson, Griffiths, & levels of satisfaction, compared with matched
Leaf, 1990). The model has been exported to cohorts who remain in hospital (Leff, 1997). The
Australia (Hambridge & Rosen, 1994) and higher levels of reported satisfaction among the
several European countries (e.g., The Nether- community cohorts seem to be directly related
lands and Italy). Such teams are beginning to to the less restrictive environments in commu-
appear in the UK (Ford et al., 1995) but progress nity residential settings. This provides a link
is slow. The model for these teams (including between quality of care measures and quality of
those that work with the homeless) is based on life indices (Abrahamson, Swatton, & Wills,
assertive outreach, with small caseloads (n = 1989; Shepherd et al., 1996). In order to improve
10±15), extended hours of operation (i.e., out- the quality of life for people with severe and
side Mon./Fri. 9±5), and the capacity to deliver enduring mental health problems we therefore
intensive support (i.e., daily visits) where need to focus on changes which will increase
necessary. their range of choices and opportunities in
It is important to distinguish between these relation to simple, everyday life goals (e.g.,
ªintensive supportº teams and ªcrisis interven- meals and mealtimes, access to rooms and
tionº services. Although the two kinds of teams personal possessions, etc.). Even in some
share some features in common (e.g., assertive community settings this may be difficult to
outreach, extended hours, intensive visiting), arrange: in hospital it is virtually impossible.
the skills mix and methods of working are quite In terms of user preferences, it is quite clear
different. Thus, crisis teams tend to be focused that most patients prefer more independent
on the short-term, with an emphasis on living arrangements, combined with flexible
symptom resolution, whereas intensive support staff support, rather than staff ªon siteº and
teams have a longer-term perspective, with having to live with a group of other people with
more of an emphasis on support and the severe mental illness (Tanzman, 1993). These
optimization of social functioning. Crisis teams aspirations are understandable, but may cause
are also much more reliant on the use of problems when it comes to the care of the most
medication, and hospitalization, with the aim of disturbed (and potentially ªriskyº) individuals.
rapid symptom stabilization, while intensive It is clearly desirable to try to offer them
support teams give more emphasis to practical placements in ordinary housing, but in practice
help, social support, and facilitating access to this may heighten fears for theirÐand others'Ð
mainstream community activities. safety. It may also provoke considerable
The final element in the necessary range of resistance from the local community if they
services to support people with serious and become aware that such developments are
enduring mental illness in the community are planned.
inpatient beds. No matter how good the Because of these problems, the Department
specialist intensive support (or crisis interven- of Health in the UK has suggested the concept
tion) teams are in the community, from time to of ª24 hour nursed bedsº in an attempt to
time inpatient admission will continue to be combine high levels of professional supervision
required. Ideally, community and inpatient with a relatively low degree of institutionalisa-
teams should work together as an integrated tion (NHS Executive, 1996). This idea is very
system, with the same medical input to both similar to the concept of a ªward-in-a-houseº or
Effectiveness and Efficiency 531
ªhospital hostelº proposed some years ago as a mental health services (Perkins, Buckfield, &
solution for some of the most difficult new long- Choy, 1997).
stay inpatients (Young, 1991). The evidence for The best controlled evidence comes from the
the effectiveness of these models has been US and this has recently been reviewed by
reviewed in Shepherd (1995) and more recently Bond, Drake, Mueser, and Becker (1997). They
in Shepherd (1998a). It seems that they may be examined seven uncontrolled and six controlled
effective in improving the functioning of up to studies of vocational rehabilitation programs
40% of those referred sufficiently for them to be and concluded that supported employment
resettled into less highly supervised accommo- models were significantly more effective in
dation in the community after an average two to achieving successful placements in competitive
three years. Residents generally make more employment compared with conventional ap-
progress than controls regarding their social proaches (unweighted mean 58% for experi-
functioning, they show increased contact with mental programs vs. 21% for controls). They
the community, and higher levels of satisfac- also suggest that ªplace-and-trainº models seem
tion. Again this seems to be associated with the much more effective than the more traditional
increased privacy and choice associated with ªtrain-and-placeº approach. Bond et al. em-
domestic scale living arrangements and the phasize the need to integrate clinical and
more ªnormalº atmosphere. For those who are vocational supports, as in the program de-
not resettled, the units are more effective in scribed by Becker and Drake (1994).
maintaining their functioning than traditional The outcome evidence from controlled trials
long-stay wards or acute admission units. Costs of specialist assertive community teams suggests
are generally less than acute beds, but greater that they can retain contact and improve levels
than long-stay wards in mental hospitals. of engagement with the most difficult and
Despite these rather positive results, such disabled people currently presenting to com-
options still remain unattractive to many of the munity services (Burns & Santos, 1995; Ford
people they are specifically designed to serve. et al., 1996). The outcomes in terms of enhanced
For them, privacy, autonomy, and practical engagement and maintained contact are parti-
help with money, food, laundry, etc. may be cularly important as loss of contact has been a
much more important than professional sup- common feature of the unfortunate incidents
port, medication, and considerations of public where community care has ªfailed.º The use of
safety (Rose & Muijen, 1997). There is therefore inpatient admission can also be significantly
a problem: on the one hand it is clearly desirable reduced without any disadvantages in terms of
to go along as far as possible with users' symptom stabilization and control (Marks et al.,
expressed preferences, or we risk losing their 1994; Muijen, Marks, Connolly, Audini, &
trust and undermining their engagement with McNamee, 1992; Olfson, 1990; Taube, Mor-
services. On the other, we need to ensure that the lock, Burns, & Santos, 1990; Wright, Heiman,
settings in which people are cared for are both Shupe, & Olvera, 1989). These effects on
cost-effective and safe. This is a real dilemma. hospitalization rates are important, both in
The only way forward would seem to continue clinical and financial terms, and seem to be
with the development of ordinary housing stronger with regard to reducing the number of
options, but combine this with intensive support days in hospital, rather than the number of
from specialized teams (see below). admissions. Costs are generally slightly lower in
In relation to work and employment, the the community treatment conditions compared
circumstantial evidence in favor of the effec- with standard hospital care, mainly because of
tiveness of work to favorable long-term out- the reduction in hospital days (Muijen et al.,
comes for people with serious mental illness is 1992; Taube et al., 1990).
very strong (Shepherd, 1997; Warner, 1985). Satisfaction ratings on the part of both
However, the specific evidence in favor of the patients and families also tend to be much
effectiveness of particular models of vocational higher for these community-based interventions
rehabilitationÐTEPs, social firms, coopera- compared with standard hospital care and this
tives, ªjob coachº models, etc.Ðis rather weak persists even when other treatment gains may
(Grove, Frendenberg, Harding, & O'Flynn, have been lost (Marks et al., 1994). This seems at
1997). Many of these projects are small scale least partly attributable to the reduced use of
and do not lend themselves easily to conven- inpatient admission, underlining the unpopu-
tional random controlled trials. Hence, most of larity of acute hospital admissions among many
the available evidence consists of uncontrolled, service users. Increased satisfaction is also
descriptive studies (e.g., McCrum, Burnside, & undoubtedly related to the greater input of
Duffy, 1997; Nehring, Hill, & Poole, 1993). An time, better continuity of care, and more
interesting recent report concerns the employ- effective follow-up, which are central elements
ment of service users in various capacities within of successful intensive community support.
There is some variability in these results, but this question is then, ªWhat kind of treatment do
is largely due to ªfidelityº problems (i.e., failure they receive while they are there?º
to adhere to interventions of known effective- Geddes et al. (1996) studied all patients
ness, see Section 6.23.8). admitted to one ward over a one-month period
In relation to crisis intervention per se, Kluiter (n=43) and found that less than two-thirds
(1997) has reviewed the outcome evidence and, (65%) received medication regimes which could
based on eight studies of home-based treatment, be said to conform to ªevidence-basedº prac-
he estimated that the average number of days in tice. Regarding therapeutic interventions other
hospital was less than a third (17:60) for the than medication, researchers from the Sains-
home-based treatment groups compared with bury Centre for Mental Health (a research-
the conventionally-treated inpatient groups. He oriented mental health charity in the UK)
concluded that various community alternatives studied over 200 consecutive admissions across
(day treatment, home-based treatment, assertive nine sites and noted a marked absence of
case management, etc.) can produce at least evidence-based practice. The most common
equivalent outcomes to inpatient admission for interventions for inpatients were ªcreativeº
the majority of those referred. Community- therapies (art, drama, music±46%), social
based services generally showed no difference activities (33%), ward groups (23%), and
with regard to symptomatic outcomes providing relaxation (21%). Only 5% of the patients
there was adequate access to accurate diagnosis received any specific psychological therapies
and effective medication regimes, social recov- (Beardsmoore, personal communication) and
ery was usually quicker and, as with longer-term there was essentially no sign of effective
intensive support, user and carer satisfaction psychosocial interventions like CBT (Drury,
was enhanced. Not surprisingly costs were less Birchwood, Cochrane, & Macmillan, 1996a,
where there were significant reductions in 1996b) or EE-based family interventions (Lins-
inpatient days (Knapp et al., 1994). zen et al., 1996). The links between community
The evidence in favor of standard acute and inpatient teams were also so weak that it
inpatient care is surprisingly limited. This is was difficult for the ward-based staff to make
particularly striking given the fact that acute valid assessments of the patients' needs and
inpatient care generally accounts for about therefore to plan effective community manage-
three-quarters of the total budget for most ment strategies. These rather depressing find-
mental health services. As indicated, acute care ings underline the gap which is still present in
has often been used as the ªcontrol conditionº many acute settings between current practice
against which various community alternatives and evidence-based regimes and highlight the
have been compared and it has seldom been important contribution that clinical psycholo-
found to be superior. Of course, it has to be gists might make to improving effectiveness in
acknowledged that most of these alternative acute inpatient settings.
community models (crisis teams, day hospitals,
etc.) are quite selective in terms of who they will
consider and there are some individuals who are 6.23.8 METHODOLOGICAL PROBLEMS
simply too disturbed, too much of a danger to
themselves or others, or too vulnerable in other Regarding the outcome literature on models
ways, for admission to be avoided. of community care, there are the usual
For example, Creed's evaluation of acute day methodological problems of poor sample
hospital treatment suggested that inpatient definition, variable quality outcome measures,
admission was only feasible for approximately unexplained sample attrition, etc. (see Shep-
60% of those referred (Creed et al., 1990). herd, 1998b). One of the more important issues
Similarly, in Hoult's famous study of commu- concerns the paucity of long-term follow-up
nity treatment in Sydney, 40% of the experi- data. The problems of living with psychosis are,
mental group were actually hospitalized initially inherently, long term and it is therefore crucial
(compared with 98% of controls). However, the that good data are available on long-term
experimental group then went on to spend an outcomes (even if this has to sacrifice some rigor
average of only 8.4 days in hospital in the in the design). Most complex psychosocial
succeeding year, compared with 53.5 days for interventions tend to show a gradual diminution
the controls (Hoult, Reynolds, Charboneau- over time, particularly after the intervention
Powis, Weekes, & Briggs, 1993). The aim of stops. This is not surprising and simply
community-based models should therefore not demonstrates the importance of maintaining
be to avoid admission ªat all costsº: it should be good continuity of care and an active state of
to offer treatment in the least restrictive, and treatment over long periods of time. Success-
most appropriate, setting and in many instances fully managing psychosis is not like prescribing
this will be hospital. The more important a course of antibiotics, it requires effective
Developing a ªUser-ledº Service 533
management strategies as well as effective without which these complex interventions do

treatment interventions (Shepherd, 1984). not seem to work. This seems to be different in
Complex psychosocial interventions must different settings. In some cases it may be
also be given sufficient time to work. It is associated with the expertise or charisma of
unreasonable to expect that significant improve- individual practitioners. In others it seems to be
ments in housing status, occupation, or social more a reflection of local conditions, ªreadiness
networks can be achieved in three (or even six) to change,º enthusiasm, staff morale, etc. In
months. Bond, Miller, Krumwied, and Ward either event the literature is full of examples of
(1988) note that such changes may take two to apparently the same intervention which works
three years and that is important to give assertive in some places, but not in others (e.g., Bond
case management programs a chance to settle et al., 1988; Creed et al., 1991). This phenom-
down. Having said this, there are also examples enon should not be dismissed as ªHawthorne
in the literature of long-term effects of case effectsº or ªnonspecifics.º It reflects the little
management programs (e.g., McRae, Higgins, understood processes of organizational change
Lycan, & Sherman, 1990). It is certainly not the and development. If we could articulate and
case that such programs cannot be sustained and define it more precisely, then clearly we would
that staff will inevitably burn out. As indicated be in a much better position to engineer more
earlier, the PACT program in Madison has been effective service change.
operating for more than 20 years and intensive
support and crisis teams now cover most of the
Australian states of New South Wales and 6.23.9 DEVELOPING A ªUSER-LEDº
Victoria. Sustainability is therefore not impos- SERVICE
sible but it depends on good training, support,
and leadership. More will be said about this in The desire to involve users (and their carers)
Section 6.23.10. more fully in the process of service planning and
A second major methodological problem delivery is now widely accepted, but most places
concerns poor fidelity of the independent are struggling to translate this laudable ambi-
variables (i.e., the interventions themselves). tion into reality. How can we appropriately
Thus, whether it is a housing project, a work involve service users when their expressed
program, or a specialist treatment team, one wishes sometimes seem unrealistic, self-defeat-
often never quite knows to what extent the ing, even frankly irrational? How can we
intervention being evaluated actually contains appropriately involve service users when, under
those elements which one would suppose, based some conditions, we are prepared to deprive
on previous research, are likely to be associated them of their liberty and force them to accept
with positive outcomes. Without a clear treatment against their will? How can we strike
specification of the independent variable results, the right balance between the needs of users and
especially negative or ªno-differenceº results, it those of carers when they often seem diame-
becomes very difficult to interpret and it is easy trically opposed?
to conclude that a particular kind of interven- These are not easy questions to answer. They
tion does not work when, in reality, it has never touch on some of the basic moral and ethical
actually been tested. This problem is particu- dilemmas in psychiatry. They are certainly very
larly important with regard to specialist com- difficult to answer in any general sense and are
munity teams where some practitioners seem to probably best addressed in relation to specific
believe that by simply calling a team intensive, instances. However, historically, the voice of the
or saying that it is practicing case management, user (and the carer) has been much neglected in
means that this is what is actually happening. psychiatry and there is therefore much to be
In order to improve the ªfidelityº of complex, done to redress the balance of power between
community interventions, Teague, Drake, and user, carer, and professional opinions. There are
Ackeson (1995) have set out some of the criteria signs that this is beginning to happen, but
that would need to be present in specialist, progress is slow. It is also clear that the
assertive, community teams if they are to adhere involvement of users in making decisions about
to models of known effectiveness. These are the content and structure of their care is now not
shown in Table 3. Such a list provides a just a matter of ethics and civil rights, it is a
convenient way for both purchasers and pragmatic necessity. Unless we can actively
providers to check on the quality of the service engage some of the most disturbed and disabled
being provided. If it does not match up to these young people currently presenting to mental
criteria, then there is little reason to suppose health services, then the consequences may be
that it will be effective. very serious for them and for others. We need to
The final methodological problem that it is give them a stronger sense that services are for
worth highlighting is the magic ingredient them and that they understand their needs and
Table 3 Ingredients of effective ªhigh supportº (assertive outreach) teams.
Small caseloads (n = 10±15)

Intensive contacts (1±2 hours/week)
Emphasis on ªassertive outreachº (i.e., > 75% of contacts in community)
Team initiates all admissions to hospital (and discharges)
ªTeamº approach to sharing difficult clients (as opposed to strict ªindividualº case
management)
Service not restricted to Mon.±Fri./9±5 pm
Regular (i.e., daily). team meetings
Clear operational management
Easy access to inpatient beds (preferably same RMO as community)
Source: Teague et al. (1995).
priorities. They need to feel some sense of what they thought was most important for the
control and ªownershipº of their own care, even care of people with schizophrenia in the
ifÐin extreme circumstancesÐthis has to be community. The data were collected across
taken away. So, what would mental health six different districts, with a mixture of rural and
services look like if they were designed by service urban settings. The patient and carer samples
users, instead of clinicians and managers? included some people who were contacted
Finding out what users really think about through mental health professionals (including
services is not easy. First, there are problems a number who were not well engaged with
with sampling and representativeness and care current services) and others who were active in
has to be taken to ensure that the group of users local user or carer groups. A mixture of
consulted does reflect the broad range of user quantitative (e.g., structured questionnaires)
opinion and is not simply constructed from and qualitative methods (e.g., focus groups)
those who are currently attending the service, or were used. The results showed a reasonably
who are already active in local user groups. good consensus between the three groups
They are, by definition, biased groups and, regarding what should be provided (housing,
although the views of ªactivistsº are obviously day care, symptomatic control, crisis planning,
important, they may not be representative of the etc.) but significant differences between them
ªsilent majorityº of those who are not active regarding the relative importance attached to
(and possibly not very engaged) in the services each element. Users emphasized the importance
they receive. of practical helpÐhousing, money, physical
The method chosen to measure users' views health careÐwhile the professionals tended to
may also significantly influence the results. For rate professional interventionsÐtreatment,
example, some qualitative approaches (e.g., support, symptom control, etc.Ðas being most
focus groups) may give very different answers important.
compared with paper-and-pencil question- There were also some interesting differences
naires. Again, this is often attributable to the between those users consulted through mental
dynamics of small groups which favor those health professionals and those contacted
who are more assertive (and generally more through the local user groups. Both rated the
ªradicalº). On the other hand, standardized, provision of information about their individual
quantitative measures may be more easily disorders (diagnosis, treatment, outcome, etc.)
replicable, but may lack the depth and ªrich- and about services in general (availability of day
nessº of more qualitative approaches (and care, accommodation options, etc.) as impor-
therefore have limited validity). A mixture of tant; both also noted the difficulties of accessing
quantitative and qualitative methods is there- professionals (or any other mental health
fore preferable (see Mechanic, 1989). With services) outside normal working hours
careful sampling and multiple methods, it is (Monday±Friday/9.00±5.00). However, as
therefore possible to survey users' and carers' might be expected, the users who were active
views and then compare these with profes- in user groups were much more radical in their
sionals' views. The results can then sometimes views and more rejecting of services aimed at
be quite surprising. providing information about medication and
For example, Shepherd et al. (1995) asked ªillness.º They clearly did not wish to accept
over 400 patients, relatives, and professionals their status as ªpsychiatric patientº and there-
Developing a ªUser-ledº Service 535
fore did not see the relevance of further have to be prepared to share information and
information. In this respect, they were different knowledge in a much more open way than has
from the majority of users and carers. been common in mental health services up to
Findings such as these suggest that users do now. For far too long mental health profes-
have different priorities from those of professionals have been overly secretive about what
sionals or managers. If they were designing they do and why. They have felt uncomfortable
mental health services they would probably about trying to answer straight questions like
begin by addressing their basic needsÐ ªWhy did I get ill? Will I get better? What do I
somewhere to live, something to do, and a have to do to prevent another breakdown?
decent level of financial support. They would Sometimes this is because they simply do not
then build clinical (ªillnessº) services in around know, not surprisingly, since these are very
this framework. Given all the difficulties difficult questions. Sometimes they may feel
discussed earlier about the development of that their credibility will be undermined if they
community services and the problems of reveal a degree of ignorance (despite the fact
interagency cooperation, even this seemingly that most patients would prefer an honest
simple prescription is not easy to meet. answer to defensive interpretation). But some-
The results also highlight the heterogenous times they may rationalize their silence by
nature of ªuser views.º Just like nurses, doctors, appeals to confidentiality and professional
or psychologists, there is no one, simple version values. In effect, whether consciously or
of users' views. They differ depending on who is unconsciously, they are then using their access
consulted and what methods are used. The to information to maintain their position of
involvement of users in service planning must power and authority. A psychoeducational
therefore proceed on the assumption that there approach fundamentally challenges this posi-
is no magic solution to the problem of user tion. Except in very special circumstances, a
consultation. A variety of methods must be psychoeducational model assumes that patients
used, with a variety of groups, repeatedly over have a right to know what professionals think
time. Perhaps most importantly, users must be they know about them and why they intend to
given the opportunity to speak directly to treat or manage them in particular waysÐ
professionals and be regularly involved in whether they agree with this or not. An
training and education programs. Only by educational model is thus very different from
regular, face-to-face contact, in a setting that a therapeutic model: good teachers aim to
allows users time to speak and professionals empower their students by sharing their knowl-
time to listen, can one be confident that the edge and skills, not disempower them by
users' agenda will be kept in the foreground. concealment and manipulation.
As indicated, one area in which the majority To date, the evidence in favor of the
of users agree is regarding the importance of effectiveness of psychoeducational approaches
information about their disorders (causes, is mixed. There do seem to be some measurable
treatments, outcomes, etc.). By giving informa- gains in knowledge resulting from the provision
tion the user is empowered to take a more active of simple, clear information to both users and
role in managing their own care just as in the carers, but the increases tend to be small and are
management of a long-term physical health heavily influenced by the receiver's precon-
condition like heart disease, diabetes, or ceived ideas (Sidley, Smith, & Howells, 1991;
asthma. The aim is to provide information Smith & Birchwood, 1987; Smith, Birchwood,
and support so that those affected can manage & Haddrell, 1992). Psychoeducation thus seems
their own disorder as much as possible and to work best when integrated with a compre-
prevent the accumulation of secondary disabil- hensive psychosocial ªpackage,º including
ities. Of course, this approach will not work problem-solving, skills training, etc. (e.g.,
with everyone (it does not work with all those Hogarty et al., 1991). At the heart of psychoe-
suffering from diabetes or coronary heart ducational packages is an attempt to help the
disease) but it does imply a fundamental shift personÐand their immediate carersÐrecognize
in attitude (and power) away from the profes- the early warning signs of possible relapse and
sional and towards the patient and his/her intervene accordingly (Birchwood et al., 1989).
family or other carers. The role of the It has been recognized for some time that
professional is then to be ªon tap, not on many patients do not relapse suddenly into a
topº providing expert knowledge and support, psychotic state. Most go through a ªprodro-
but not taking away from the individual their malº (i.e., prepsychotic) period, often charac-
ultimate responsibility for their own health care terized by an increase in neurotic symptoms
and its management. (agitation, sleeplessness, poor concentration)
If professionals are going to be able to before clear psychotic symptoms appear.
function in this new kind of role, then they will Around two-thirds of people with relapsing
psychosis can accurately report these early psychological issues around medication com-
warning signs and over three-quarters of pliance. The effectiveness of medication in the
relatives and other carers (Herz & Melville, treatment and management of severe mental
1980). Furthermore, the particular pattern of illness is, after all, as much determined by the
symptomatic changes is often highly specific to psychological decisions surrounding the deci-
each individual patient: they might therefore be sions to take it (or not) as it is about its
said to possess a kind of personalized relapse pharmacological action.
ªsignatureº (Birchwood, Macmillan, & Smith, A psychoeducational format therefore in-
1992). The potential importance of identifying volve users in their own care in a way that is
such relapse signatures is obvious. Close quite different from the traditional patient±
monitoring of prepsychotic symptoms may therapist relationship. The therapist talks
enable patients and clinicians to work together openly about symptoms, he/she acknowledges
much more effectively and thereby manage with that these experiences are not uncommon, and
significantly lower overall doses of medication. that it isn't therefore just a personal nightmare.
Since the prevalence of drug side effects is very The individual is thus helped to develop a new
much related to the size of the dose, and since ªrelationshipº with their disorder. Instead of
for many patients it is the severity of side effects being, ªa schizophrenic,º they become, ªa
which most significantly influences their deci- person who is trying to manage their schizo-
sion to continue (or not) with medication, these phrenia,º not a schizophrenic. There is a
approaches hold out considerable promise in parallel here with people with anxiety or
improving medication compliance and deliver- depressive symptoms who develop a different
ing the maximum positive benefits from relationship with their symptoms as a result of
pharmacological interventions while minimiz- successful treatment. They start to see the
ing their adverse side effects. possibility of exerting some degree of control
Other psychological approaches to improv- over these painful and distressing experiences,
ing compliance by involving users more fully in rather than being controlled by them. This can
their own treatment and management plans be the basis for a more positive adjustment to
have now also been developed (e.g., Corrigan, their condition.
Liberman, & Engel, 1990; Eckman, Liberman,
Phipps, & Blair, 1990; Eckman et al., 1992). One 6.23.10 STAFF TRAINING
of the most interesting is the application of a
technique known as ªmotivational interview- All this implies some very fundamental
ing.º This was originally formulated to assist changes in the way that mental health profes-
people with tackling problems of drug or sionals are currently trained and supported.
alcohol abuse and is based on the assumption What do we need to make staff more effective in
that most important behavioral choices contain working with people with severe and enduring
some element of conflict (e.g., ªHow do I weigh mental health problems?
up the immediate benefits of alcohol or other First, we need to ensure that they are able to
drug consumption against its longer-term ill deliver the range of psychosocial treatments of
effects ?º). In the case of medication compliance known effectiveness. We have emphasized
in schizophrenia, the question is, ªHow do I throughout this chapter that rehabilitation must
weigh up the degree of symptom relief asso- proceed from a basis of effective treatment, yet it
ciated with taking my medication, as opposed to is still rare to find staff who are well enough
the clear disadvantages in terms of side trained to deliver the full range of psychosocial
effectsÐlethargy, tiredness, weight gain, loss interventions that have been demonstrated to be
of libido, etc.?º The motivational interviewing effective with this client group. For example,
intervention is built around a structured despite the familiar problems of lack of general-
exploration of these conflicted beliefs and an ization and maintenance, traditional skills
effort is made to encourage maximum personal training models clearly have some value in
commitment to whatever final decision is promoting the acquisition of social and other
reached (Miller & Rollnick, 1991). Results from skills (Corrigan, 1991). The effectiveness of skills
a random controlled trial using this approach training models are also likely to be enhanced if
suggest that such interventions cannot only they are combined with suitable medication
improve compliance and enhance symptomatic regimes, behavioral family management pro-
outcomes, they can also increase community grams, and psychoeducational approaches (Ho-
tenure up to 18 months postdischarge (Kemp, garty et al., 1991). Similarly, the evidence for the
Hayward, Applewhaite, Everitt, & David, effectiveness of EE-based family interventions in
1996). Such results are very encouraging and preventingÐor at least postponingÐrelapse in
one would hope to see more of these new schizophrenia is now very strong (Barrowclough
approaches aimed at addressing some of the & Tarrier, 1998; Mari & Streiner, 1994), again
Staff Training 537
particularly in combination with medication and homes, in the street, in shops, the park, the pub,
psychological interventions. Finally, CBT has and the cafe. Staff need to be prepared to work
produced some promising evidence for its outside normal offices and formal facilities; they
effectiveness in terms of reducing symptom must be prepared to work alongside the user in a
severity and alleviating some of the subjective variety of apparently mundane activities and
distress associated with residual psychotic recognize that these are all vital opportunities for
symptoms in outpatient samples (Kuipers assessment and treatment. They must be creative
et al., 1997) and, as indicated earlier, there are in their ability to exploit these contacts and to
some very interesting reports of CBT applied in extract the maximum therapeutic benefit from
inpatient settings resulting in significantly more what may often be unconventional encounters.
rapid symptomatic recovery and reduced overall Staff must also be very clear about the limits of
lengths of admission (Drury et al., 1996a, their own competence (whatever their specific
1996b). There is thus a very strong evidence areas of expertise) and be prepared to enlist the
base for the effectiveness of a number of psycho- help of colleagues from the same or other
logical approaches and a considerable task to be agencies (e.g., in housing, employment agencies,
done in terms of training and supporting staff to etc.) who also have expert knowledge in their
implement such interventions. own fields. This openness to working with others
Staff must also be prepared to deliver care and clear recognition of one's own limitations
which is sensitively tuned to the ªuser agenda.º are key ingredients for effective staff working
As indicated earlier, this means that services with this client group.
have to be delivered much more on the user's Can we say anything more about the kind of
terms and much less according to a ªprofes- personality that we should be looking for? As
sional viewº of what is most important. This can indicated earlier, the concept of low EE has
be difficult for those staff with a strong desire to recently been extended to staff and other
show off their therapeutic skills, but there is a informal carers (Ball et al., 1992; Moore et al.,
kind of ªhigher professionalismº which recog- 1992) and this forms a useful framework for
nizes that sometimes sorting out someone's thinking about staff characteristics. It is a
housing benefits and finding them meaningful common clinical observation that staff often
work is more importantÐand makes a better make the same ªblame attributionsº for negative
starting pointÐfor a therapeutic relationship symptoms which seem to underlie the responses
than delivering ªstate-of-the-artº cognitive- of high EE relatives (Brewin, MacCarthy, Duda,
behavioral intervention for residual psychotic & Vaughn, 1991). It is therefore possible that the
symptoms, or detailed assessments of cognitive same kinds of educational and skills-based
functioning, self-care skills, etc. programs that have been developed for families
Staff must also be credible. What makes staff (e.g., psychoeducation, problem-solving, com-
credible will be different for different users: munication training, etc.) may be equally
some may prefer younger workers, some may relevant for staff (Ranz, Horen, McFarlane, &
prefer older, some may prefer the same gender, Zito, 1991). Low EE staff will not get too
same ethnic group, etc. Whatever their back- irritated or frustrated in the face of repeated
ground, users must feel that the worker has a failure and avoid blaming the patient for his or
real understanding of their situation and is able her difficulties. This does seem to be related to a
to offer something constructive to help. Teams particular kind of personality type, but may also
therefore require a mixture of ages, back- be facilitated by having clear and realistic
grounds, experience, etc. Some users may even expectations for change, which in turn is based
prefer staff who themselves have direct experi- on good support and supervision.
ence of receiving mental health services and Effective leadership, organization, and man-
there are some interesting examples from the US agement of staff are therefore also crucial.
of service users receiving training and then Leaders can be from any discipline, but they
acting as case managers (e.g., Mowbray et al., need both good analytic skills (to break down
1996; Solomon & Draine, 1995). problems, set priorities, assign tasks, etc.) and
But it is not sufficient that staff simply have an good socio-emotional skills (to involve and
intellectual understanding of users' problems, support others, develop a strong sense of
they must be able to empathize with their common ownership, commit them to carrying
situation and convey this effectively. Users out agreed actions, etc.). There is a strong
should also feel that staff like them (at least consensus now regarding the importance of
most of the time!). Sensitivity, humor, honesty, team case management systems, as opposed to
warmth may all sound like cliches, but they are individually-based case managers (Stein, 1992;
central to forming effective working relation- Test, 1979). Obviously, there have to be clear
ships in this, as in any other, form of therapeutic individual accountabilities, but this does not
activity. Users may need to be seen in their own remove the necessity for good teamwork and
sharing of responsibilitiesÐand, to a certain to live, something to do, and a decent level of

extent, clientsÐwithin the team. This is neces- financial support. These do not seem unreason-
sary to cover for staff when they are absent or able, or unrealistic, demands, but it is still rare
unavailable. Effective teamwork is really the to find them completely met. Similarly, staff
only way in which good continuity of care can need to be trained in effective interventions and
be maintained. then organized and supported in such a way that
In the UK, the management of community these can be delivered in the most efficient way
teams has been identified as an important area possible. Again such conditions are rarely met.
of weakness (Onyett, Pillinger, & Muijen, 1994). Finally, there are families and other carers.
This has been partly attributed to a lack of Families provide more health care than any
managerial authority on the part of team formal system of professional care ever does, or
leaders, related to the continuing tension ever will do, and severe and enduring mental
between professional and operational manage- illness is no exception. Yet families are still often
ment. The outcome of this confusion is a lack of ignored, seldom consulted, and sometimes even
clarity regarding the roles and accountabilities blamed for being the cause of the problem. It is
of individual staff and this is associated with not surprising that many are frustrated to the
feelings of dissatisfaction and emotional ex- point of bitterness, asking ªHow long will it be
haustion (burnout). Onyett et al. argue that in before we are treated as genuine partners in
order to counteract this, team leaders should care?º As professionals we have a responsibility
have clear managerial authority over opera- to respond to this question and to ensure that
tional matters (i.e., day-to-day running of the families are included in the process of care and
team) even if this means weakening professional not simply exploited as a convenient (and
line management. This may be controversial in cheap) resource.
some countries, but seems necessary if teams are So, there is much to be done. But, never-
to function effectively. theless I am optimistic. I believe that systems of
In the end, teams are delicate and complex care for people with severe and enduring mental
structures. They require good training, good illness have generally improved over the last 40
leadership, good organization and manage- years and there are some outstanding examples,
ment, and good support. None of these in several countries, of truly comprehensive,
components can be ignored if they are going community-based services which do address
to function to their maximum effect. peoples' housing, vocational, social, and clinical
needs. Our task is to make these the norm rather
6.23.11 CONCLUSIONS than the exception. To achieve this, we must
combine what the Italian philosopher Gramsci
This chapter has covered a considerable range referred to as, ªThe optimism of will, tempered
of topics. The effective treatment and manage- with the pessimism of reason.º This is surely the
ment of people with severe and enduring mental task for the next millenium.
health problems raises issues at all levels of
servicesÐindividual, team, facility,
subcultureÐand these are played out differently 6.23.12 REFERENCES
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6.24
Somatoform Disorders
GEORG H. EIFERT and CARL W. LEJUEZ
West Virginia University, Morgantown, WV, USA
and
THEO K. BOUMAN
University of Groningen, The Netherlands
6.24.1 CLINICAL PICTURE 544

6.24.1.1 DSM-IV Classification 544
6.24.1.2 Disease, Illness, and Somatization 545
6.24.2 HISTORICAL PERSPECTIVES AND DIAGNOSTIC CHANGES 546
6.24.2.1 Somatization Disorder 546
6.24.2.2 Hypochondriasis 546
6.24.2.3 Pain Disorder 546
6.24.2.4 Conversion Disorder 547
6.24.2.5 Body Dysmorphic Disorder 547
6.24.3 PREVALENCE, COURSE, AND DEVELOPMENT 547
6.24.4 PROBLEMS OF DIFFERENTIAL DIAGNOSIS AND COMORBIDITY 549
6.24.4.1 Somatoform Disorders vs. General Medical Conditions 549
6.24.4.2 Differentiating Somatoform Disorders 550
6.24.4.2.1 Somatization disorder vs. hypochondriasis 550
6.24.4.2.2 Somatization disorder vs. pain disorder 550
6.24.4.2.3 Somatization disorder vs. conversion disorder 550
6.24.4.2.4 Hypochondriasis vs. body dysmorphic disorder 550
6.24.4.3 Relation Between Somatoform Disorders and Depression 551
6.24.4.4 From Differential Diagnosis to Dimensional Classification 551
6.24.4.4.1 Hypochondriasis and disease fear: a dimensional perspective 551
6.24.4.4.2 Relation between hypochondriasis and anxiety disorders 552
6.24.5 CONTEMPORARY THEORETICAL PERSPECTIVES 553
6.24.5.1 Dysfunctional Processes in the Somatoform Disorders 553
6.24.5.1.1 Abnormal illness behavior 553
6.24.5.1.2 Perception and attention 553
6.24.5.1.3 Deficits in emotion processing (alexithymia) 554
6.24.5.2 Disorder-specific Theoretical Models 554
6.24.5.2.1 Hypochondriasis 554
6.24.5.2.2 Pain 555
6.24.5.3 Future Challenge: Integrative Biobehavioral Theories 556
6.24.6 TREATMENT OF SOMATOFORM DISORDERS 557
543
544 Somatoform Disorders

6.24.1 CLINICAL PICTURE move beyond DSM categories toward a more

function-based dimensional perspective of the
Many individuals present to medical practi- problems of persons who present with either
tioners with physical complaints for which no unexplained somatic symptoms or excessive
medical explanation can be found. For instance, concerns over physical symptoms. We believe
a European study (van Hemert, Hengeveld, that such an approach is clinically more
Bolk, Rooijmans, & Vandenbroucke, 1993) beneficial because it provides information that
found that among 191 new referrals to a general is directly useful for the design of clinical
medical outpatient clinic, 52% of patients had interventions.
symptoms that ultimately remained unex-
plained. An earlier Australian study reported
that of 95 patients visiting a general practitioner 6.24.1.1 DSM-IV Classification
and presenting with somatic complaints, 41%
had no demonstrable somatic pathology (Pi- The present classification of somatoform
lowsky, Smith, & Katsikitis, 1987). Comparable disorders stems from the DSM-III taskforce
percentages have been reported in other studies decision to eliminate the concept of neurosis
from different countries investigating unex- because of its etiological connotations. This
plained symptoms of patients with abdominal change resulted in disorders previously classified
pain (Harvey, Salih, & Read, 1983) and chest in one category as neuroses (anxiety neurosis,
pain (Eifert, 1992; Mayou, Bryant, Forbar, & neurotic depression, hypochondriasis, and hys-
Clark, 1994). teria) to be redefined and reclassified in four
Although many of these patients will be separate DSM categories: anxiety disorders,
satisfied with negative medical examination mood disorders, somatoform disorders, and
results, and some reassurance to that effect, a dissociative disorders (Murphy, 1990). Accord-
significant subgroup will anxiously continue to ing to DSM-IV (APA, 1994), the common
ruminate about the possibility of suffering feature of the somatoform disorders is the
from a yet-undiagnosed physical disease. They presence of physical symptoms that suggest a
are likely to continue to seek help for the same general medical condition (hence, the term
or different physical symptoms, demand more somatoform) but are not fully explained by a
physical examinations and specialist referrals, general medical condition, the direct effects of
undergo costly laboratory tests, and, in some substance, or by another mental disorder.
cases, even end up on an operating table Physical symptoms result in substantial perso-
(Warwick & Salkovskis, 1990). Despite the nal, social, and occupational impairment, and
high prevalence of ambiguous and unexplained are not feigned or voluntarily produced, as in
physical problems, somatoform disorders have malingering or factitious disorder.
received only minimal research attention and DSM-IV distinguishes between six somato-
are poorly understood. A major reason for this form disorders: somatization disorder, undif-
relative lack of knowledge is that persons with ferentiated somatization disorder, conversion
such problems are typically reluctant to see a disorder, pain disorder, hypochondriasis, and
psychologist and prefer to remain within the body dysmorphic disorder. These disorders can
medical service system. As a result, they have be categorized under two larger headings of the
literally evaded the attention of clinical classical ªhysterical disordersº and ªpreoccupa-
psychologists. tion disorders.º Hysterical disorders involve
We have organized our discussion in this actual loss or alteration in bodily functions as in
chapter around the categories and classification the case of somatization disorder, conversion,
put forward in the Diagnostic and statistical and pain disorder. Reports of suffering often
manual of mental disorders (4th ed., DSM-IV; exceed symptom reports of patients with known
American Psychiatric Association [APA], medical illnesses. Patients with hysterical dis-
1994). There is considerable overlap between orders typically experience no anxiety, whereas
somatoform disorders and several of the anxiety persons with preoccupation disorders are
disorders. We will therefore make an attempt to excessively concerned that there is something
Clinical Picture 545
physically wrong with their body either in terms edge. DSM-IV describes four subtypes with (i)
of disease (hypochondriasis) or in terms of the motor symptoms or deficits (e.g., paralysis), (ii)
shape and size (body dysmorphic disorder). The seizures of convulsions, (iii) sensory symptoms
general features of each of these disorders will or deficits (e.g, blindness, anesthesia, and
be outlined below. aphonia), and (iv) a mixed presentation. Some
Somatization disorder is characterized by patients show an indifference or lack of worry
multiple physical complaints without clear or about their symptoms (la belle indifference). An
known physical causes. The condition may last important requirement for the diagnosis is the
for many years and, in some cases, extend over temporal relation between conversion symp-
the entire adult life-span. To make the diag- toms and a psychological stressor such as acute
nosis, an individual needs to present with a grief or victimization. Patients are typically
history of pain related to at least four different unaware of the psychological basis for their
sites or functions (e.g., head, back, abdomen, symptoms and report being unable to control
joints), two gastrointestinal symptoms (e.g., them.
diarrhea, food intolerance), one sexual symp- Body dysmorphic disorder (BDD) is char-
tom (e.g., irregular menses, indifference to sex), acterized by a preoccupation with an imagined
and one pseudoneurological symptom (e.g., or exaggerated body disfigurement or an
poor balance, numbness, paralysis). These excessive concern that there is something wrong
symptoms lead to frequent and multiple medical with the shape or appearance of one's own body
consultations, complex medical history, and to parts. The perceived defect or abnormality is
alterations of the person's lifestyle. Physical and generally not or hardly noticeable to others.
laboratory findings cannot detect a plausible Objects of concern typically refer to the face
medical condition to be the cause of the (nose, mouth, eyes, teeth), head (hair thinning),
symptoms, and if a cause exists, the patient's sexual characteristics (size of penis, breasts), or
reaction seems to be in excess of what would be general body appearance (too long or too short,
expected. ugliness). Other concerns may involve scars,
Hypochondriasis is characterized by unjusti- wrinkles, or body odor. Cognitive features are
fied fears, suspicions, or convictions that one excessive preoccupation, intrusive thoughts, and
has a serious and often fatal illness such as heart sometimes ideas of reference. On a behavioral
disease, cancer, or acquired immune deficiency level, features include avoidance (e.g., of body
syndrome (AIDS). Patients frequently seek exposure, direct social contact, talking about the
reassurance, check their bodies, and avoid problem, looking in the mirror), camouflaging
illness-related situations. Merely informing or concealing of imagined deformities (wearing a
patients of the absence of a disease process, hat or glasses), excessive grooming and check-
or explaining the benign nature of the symp- ing, and reassurance seeking.
toms, only results in temporary reassurance
which is followed by renewed worry over
symptoms and continuing overuse of medical 6.24.1.2 Disease, Illness, and Somatization
services (Salkovskis & Warwick, 1986).
Pain disorder is characterized by severe acute Disease is often described as the presence of
or chronic pain in one or more body parts. The objective biological abnormalities in the struc-
pain is not easily understood, or cannot be fully ture and/or function of bodily organs and
accounted for, by a known medical condition. systems. Illness refers to the subjective percep-
Pain is ipso facto a subjective phenomenon and tion of being unwell, and may be unrelated to
psychological factors such as mood, anxiety, the presence of an objectifiable disease. The sick
and attention may be involved in the onset, role is a sociological construct initially put
maintenance, or exacerbation of pain and forward by the American sociologist Talcot
complicate differential diagnosis. Pain is con- Parsons pertaining to a role granted to an
sidered acute when it exists for less than six individual by society with accompanying privi-
months and chronic when it persists beyond six leges (e.g., staying home from work) and
months. Chronic pain, in particular, is often obligations (complying with medical regimens).
associated with major changes in behavior such Pivotal to the somatoform disorders is the
as decreased activity and somatic preoccupation phenomenon of somatization, defined by Li-
(Pilowsky, Chapman, & Bonica, 1977). powsky (1988, p. 275) as ªa tendency to
Conversion disorder is characterized by experience and express psychological distress
symptoms suggesting a neurological disorder, in the form of somatic symptoms which the
although appropriate medical investigations fail individual misinterprets as significantly serious
to identify a neurological or general medical physical illness and seeks medical help for
disorder. At times, symptoms may even be them.º Rather than referring to a discrete group
inconsistent with general neurological knowl- of disorders, this definition reflects the current
opinion of somatization as a complex psycho- are judged to be associated with the symptom or
pathological process that may be involved in a deficit because the initiation or exacerbation of
variety of clinical problems (cf. Kellner, 1986). the symptom or deficit is preceded by conflicts
Psychosomatic disorders have traditionally or other stressorsº (APA, 1994, p. 457).
been regarded as medical conditions in which
psychological factors play a role. The concept of
psychosomatic disorders is misleading, how- 6.24.2.1 Somatization Disorder
ever, because it presupposes a special class of Somatization disorder is the current term for
somatic disorders of psychogenic etiology what is arguably the oldest mental health
(Lipowsky, 1988). A conceptually more neutral diagnosis, ªhysteria.º More than 2000 years
concept is that of ªfunctional somatic symp- ago, the ancient Greeks believed that multiple
toms,º which Kellner (1986) defined as somatic somatic symptoms were caused by the uterus
symptoms that are not attributed to organic wandering through the female body. In the
pathology demonstrable by physical examina- middle of the nineteenth century, the French
tion or routine laboratory testsÐalthough physician Briquet described a polysymptomatic
transient physiological changes may be found somatic condition (ªBriquet's syndromeº),
in some of the disorders or can be detected by which was redefined in the 1950s as somatiza-
special techniques such as measurement of tion disorder (cf. Bass & Murphy, 1990) and
bowel contractions or of changes in striated became the basis for the current diagnostic
muscle tension. entity.
Conceptual proliferation and confusion dom-
inate the field of somatization and somatoform
disorders. Many concepts are used interchange- 6.24.2.2 Hypochondriasis
ably or remain ill-defined in research and
clinical practice. Despite considerable comor- Hypochondriasis is a Greek word meaning
bidity, and even phenomenological overlap ªbelow the cartilage.º The ancient Greeks
between psychological and somatic disorders, derived the concept of hypochondriasis from
Cartesian dualism is still implicitly or explicitly humoral theories of disease and considered it a
influential in clinical practice. This may, in part, special form of melancholia resulting from an
be due to the traditional division of labor excess of black bile. In the seventeenth century,
between medical and psychological disciplines, Thomas Sydenham, an English physician,
each claiming (or hoping) to answer some of the argued that hypochondriasis occurred only in
questions in the mind±body realm. Such reduc- men and was equivalent to hysteria occurring in
tionist models, however, are a serious obstacle females. Also around this period, Descartes
to a more comprehensive understanding of proposed that the mind and body were separate
somatoform disorders. entities, and there could be no causal relation
between the two. Subsequent psychodynamic
views suggested that hypochondriacal patients
direct their libido inwards, whereas healthy
6.24.2 HISTORICAL PERSPECTIVES AND persons typically direct their libido at external
DIAGNOSTIC CHANGES objects. Eventually, internally directed libido
Early views of somatoform disorders as- would build up and result in physical symptoms
sumed that these disorders have common roots (Freud, 1956).
and are somehow related to the female
reproductive system. The French neurologist 6.24.2.3 Pain Disorder
Charcot (1825±1893) demonstrated that ªhys-
terical conversions,º involving symptoms such Throughout history, there has been consider-
as convulsions and paralysis, could be induced able speculation concerning the nature and
by hypnotic techniques. He assumed that cause of pain. For instance, Aristotle viewed
conversions originate from mental rather than pain as an emotion as opposed to a sensation,
physical processes. Physical symptoms were Descartes viewed it as a result of physical stimuli
regarded as a defense mechanism against impinging upon the body, Epictetus viewed it as
unacceptable unconscious conflicts where mas- the result of cognitive activity, and religious
sive repression forces psychic energy to be leaders viewed it as a test of faith imposed by
transformed into bodily symptoms. Although god or punishment for sins (Turk, Meichen-
specific psychodynamic notions have been baum, & Genest, 1983). A commonality of these
eliminated from the current DSM-IV, conflict early theories was a unidimensional view of
is still believed to be involved in some of the pain. Theories were based either upon organic
somatoform disorders. For instance, in the case or psychological causes, and few attempted to
of conversion disorders ªpsychological factors integrate the two. It was not until the twentieth
Prevalence, Course, and Development 547
century that Cartesian dualism was seriously ing, factors such as parental rearing and
questioned and multidimensional theories of childhood development, stressful life events,
pain began to develop. high negative affect, and aspects of the relation-
ship and communication between patients and
doctors have been related to the development of
6.24.2.4 Conversion Disorder somatoform disorders (e.g., Bass & Murphy,
The origin of the contemporary concept of 1990; Craig, Boardman, Mills, Daly-Jones, &
conversion disorder can be traced back to the Drake, 1993).
Middle Ages when ªconversioº referred to
diseases caused by a ªsuffocation of the womb.º
6.24.3.1 Somatization Disorder
Freud considered conversion a form of defense
in which the resulting symptoms were fixations Somatization disorder is a relatively rare
of physical patterns relating to events at the time phenomenon with recent community studies
of a patient's (sexual) trauma (Mace, 1992). citing prevalence rates between 0.4% and 0.7%
Primary gain was seen as the warding off of (cf. Bass & Murphy, 1990). Its onset is in early
these forbidden impulses, whereas secondary adulthood, course is often chronic, and prog-
gain was the attention and privileges patients nosis is generally regarded as poor. Somatiza-
received. The loss of bodily functions in tion is associated with frequent absences from
conversion disorder was thought either to be work or school, overuse of medical care, and
the direct effect of the trauma or to symbolize excessive use of drugs and alcohol (APA, 1994).
the unconscious conflict. In recent years sexual abuse and traumatization
have been cited as a precursor of somatization
disorder (Salmon & Calderbank, 1996). For
6.24.2.5 Body Dysmorphic Disorder
instance, female psychiatric patients with so-
The term ªdysmorphophobiaº was coined in matization disorder have reported more sexual
the late nineteenth century by the Italian and physical abuse than patients with other
psychiatrist Enrico Morselli (cf. Berrios & disorders (Pribor, Yutzy, Dean, & Wetzel,
Kan, 1996). Based upon his clinical observa- 1993).
tions, Morselli described a condition in which
there is a sudden onset and subsequent
persistence of an idea that the body is (or might 6.24.3.2 Hypochondriasis
become) deformed. Morselli stressed the ob- Most prevalence research related to hypo-
sessive nature of this condition and the strong chondriasis has been conducted in some type of
desire to check the perceived body abnormality. medical or psychiatric setting and results have
Although Morselli described his patients as been inconclusive (cf. Iezzi & Adams, 1993).
being fearful about their deformities, more Research has been impeded by the use of
recent investigations (e.g., Fava, 1992a) could different definitions of hypochondriasis. For
not substantiate the presence of phobic anxiety example, Kenyon (1976) used a strict definition
in this condition. As a result, the term and determined that 3±14% of patients in a
dysmorphophobia was abandoned in DSM- medical setting were hypochondriacal. With
IV and replaced with the diagnosis of body regard to illness fears, Agras, Sylvester, and
dysmorphic disorder (cf. Bass & Murphy, 1995). Oliveau (1969) interviewed 325 randomly se-
lected subjects from the general population and
6.24.3 PREVALENCE, COURSE, AND found that 16% had fears of illness and 3.1%
DEVELOPMENT qualified as having an illness phobia. Moreover,
individuals with frequent exposure to medical
There is a preponderance of studies showing settings (e.g., medical students) appear to have
that the presentation of symptoms for which no increased health concerns (Hunter, Lohrenz, &
demonstrable organic pathology can be found is Schwartzman, 1964; Jacob & Turner, 1984). The
a common occurrence in a variety of medical onset of hypochondriasis is frequently in early
settings (Pilowsky et al., 1987; van Hemert et al., adulthood. Although symptoms may wax and
1993). Yet the exact prevalence of somatoform wane, the course is typically chronic and the
disorder is still unclear. This is largely due to the condition frequently takes a dominant role in
fact that studies frequently did not adequately the person's life and relationships.
differentiate between somatoform and related In children, somatic complaints and atten-
disorders (e.g., anxiety, depression), and epide- tion to physical symptoms have been shown to
miological studies have used various diagnostic be influenced by attention received from
criteria and different samples (cf. Kellner, parents (Mechanic, 1964). In addition, adult
1986). Although systematic knowledge is lack- patients who rate themselves as having high
hypochondriacal concerns describe their par- shows pain patients as a homogeneous and
ents as more caring and overprotective than separate group from individuals without pain
patients with other psychiatric disorders (Parker (Love & Peck, 1987; Turk & Flor, 1984; Turk &
& Libscombe, 1980). Studies also found that Salovey, 1984). Consequently, in the place of
somatic symptoms of child and adult hypo- uniformity, many researchers have begun to
chondriacal patients resemble those of their look for subgroups with different psychological
parents (Apley, 1958). An individual's percep- profiles (Armentrout, Moore, Parker, Hewett,
tion of and exposure to physical symptoms and & Feltz, 1982; Jensen, Turner, Romano, &
disease in the family, in combination with Karoly, 1991). Apart from a high frequency of
parental attitudes towards illness influencing prior physical abuse, sexual abuse, and other
the development of hypochondriacal concerns trauma, occupational factors play an important
in children (Eifert, 1992; Flor, Birbaumer, & role. For instance, overuse of a body part has
Turk, 1990; Kellner, 1985). These concerns are been shown to lead to specific pain syndromes
likely to continue into adulthood, particularly (Newmark & Hochberg, 1987; Schuldt, Ec-
when persons experience symptoms that they kholm, Harms-Ringdahl, Aborelius, & Nemeth,
cannot easily explain or understand. For 1987).
instance, Eifert and Forsyth (1996) found that
exposure to heart disease in parents may make 6.24.3.4 Conversion Disorder
observing children more vulnerable to develop-
ing fears of heart disease. Furthermore, the Isolated conversion symptoms are believed to
death or terminal illness of a relative or friend be fairly common and symptoms often disappear
has also been shown to precipitate hypochon- after a relatively brief period. In contrast, the
driacal fears and behaviors with developing diagnosis of conversion disorder is rare and
symptoms often resembling the deceased rela- difficult to establish with estimates ranging
tive's symptoms (Eifert, Hodson, Tracey, between 0.001% and 0.3% (APA, 1994). One
Seville, & Gunawardane, 1996; Parkes, 1972). reason is that symptoms seemingly indicative of
Finally, sexual trauma has also been linked to conversion disorder are later discovered to be
the development of excessive health anxiety. linked to a gradually developing, physical
Barsky, Brener, Coeytaux, and Cleary (1995) (neurological) disease such as a brain tumor or
found that hypochondriacal hospital outpati- multiple sclerosis (cf. Fishbain & Goldberg,
ents recalled more childhood trauma (parental 1991). Although this condition may occur at any
upheaval, sexual trauma, and beatings) before age, onset is typically in late childhood or early
the age of 17 years than a patient control group. adulthood. Onset is often sudden and in response
to conflicts or stressful situations such as
6.24.3.3 Pain Disorder unresolved grief and sexual trauma. Emotional
stress was found to be present before the onset of
The exact prevalence of pain disorder is conversion in 87% of the 53 outpatients in an
unknown, but it appears to be relatively Indian study by Sharma and Chaturvedi (1995).
common and may occur in adults of all ages. According to DSM-IV (APA, 1994), conversion
For example, pain is the most common is five times more common in women than in men
complaint of individuals presenting to a and more common in persons of lower socio-
physician (Ford, 1995). The proliferation of economic status with limited medical or psy-
special pain clinics could be seen as another chological knowledge.
indication of the high number of pain patients
seeking professional help. According to DSM- 6.24.3.5 Body Dysmorphic Disorder
IV (APA, 1994) estimates, in any given year,
10±15% of adults in the United States have The prevalence of BDD is largely unknown,
some form of work disability due to back pain but preoccupation with body image and dis-
alone. A study of internal medicine private satisfaction with some aspect of one's appear-
practice patients found that 13% of patients ance are believed to be widespread in the general
suffered from chronic pain (Margolis, Zimny, & population. In fact, according to DSM-IV
Miller, 1984). Using a sample of HMO (APA, 1994), BDD may be more common than
enrollees, von Korff, Dworkin, and LeResche was previously thought and under-recognized in
(1990) observed that 45% of individuals settings where cosmetic procedures are per-
reported persistent or recurrent pain with 8% formed. In terms of a diagnosable condition,
reporting severe pain and 2.7% reporting severe Rosen (1995) found that about 1% of a
pain that limited their normal activity. community sample met criteria for BDD with
Although research aimed at determining the virtually no gender differences in prevalence.
prototypical pain patient continues (cf. Gamsa, Onset of BDD may be gradual or sudden, and
1994), there is no compelling evidence that its course is generally continuous and chronic,
Problems of Differential Diagnosis and Comorbidity 549
though fluctuating in intensity. At present, we able for diagnosing somatoform disorders and
have only fragmentary and anecdotal reports on useless for the purpose of designing treatments.
etiological factors, and no prospective long- Symptom-focused diagnoses may be artifacts
itudinal study of BDD has been undertaken biased by patient suggestibility and a clinician's
(Rosen, 1995). Nevertheless, BDD is thought to preoccupation for some disease. Rather than
start in adolescence when preoccupation with the presence of a specific set of physical
physical appearance is very common. Socio- symptoms, it is the way a patient interprets,
cultural factors influencing people's attitudes experiences, and responds to a symptom that
towards and dissatisfaction with their bodies constitutes psychopathology (Fink). In parti-
seem to play a role in determining the extent to cular, a somatic attributional style (Robbins &
which a real or imagined physical abnormality Kirmayer, 1991) may contribute to the transla-
becomes a cause for concern and preoccupation of personal and social problems into
tion. Perfectionistic features seem to be related physical symptoms, and prompt patients to
to BDD (Frost, Williams, & Jenter, 1995). present with somatic distress and request
somatic treatments.
In sum, the diagnostic validity of somatoform
6.24.4 PROBLEMS OF DIFFERENTIAL disorders in relation to each other as well as to
DIAGNOSIS AND COMORBIDITY other clinical syndromes is problematic. The
problem even extends to the distinction between
The diagnostic validity of the somatoform the somatoform disorders and general medical
disorders has been questioned repeatedly and conditions. Using a categorical classification
for good reason. Even the authors of the DSM- system, diagnostic distinctions cannot be made
IV concede that the grouping of these disorders to a satisfactory degree. What is needed is a
in a single section is based on clinical utility multidimensional classification system incor-
rather than on assumptions regarding shared porating psychological, somatic, and social
etiology or mechanisms (APA, 1994). Murphy dimensions (cf. Mayou, Bass, & Sharpe,
(1990) indicated that the disorders are not 1995). Nonetheless, in the present diagnostic
qualitatively distinct but rather merge into each criteria the origin of somatic complaints
other, making distinctions between individual assumes an important role for differential
somatoform disorders hard to define. As an diagnosis. DSM-IV distinguishes symptoms as
example, pain may occur in any of the part of a ªreal diseaseº (general medical
somatoform disorders. Ambiguous normative condition) from symptoms that are under a
criteria such as ªthe person's concern is patient's voluntary control or intentionally
markedly excessive,º ªgrossly in excess of what produced. We will therefore briefly discuss
would be expected,º and ªslight physical attempts to distinguish somatoform disorders
abnormalityº create further problems. The from each other and from a general medical
distinction between BDD and normal concerns condition. The interesting relation between
about appearances are as difficult to make as the somatoform and anxiety disorders will then
distinction between BDD and delusional dis- be discussed to show how a classification system
order (somatic subtype). The relation and that focuses on the functions of maladaptive
distinction between somatoform disorders and health-related behaviors, and defines problems
personality disorders have also recently been in a dimensional rather than categorical
questioned (Bass & Murphy, 1995; Tyrer, 1995). manner, may be more beneficial for clinicians,
On the other hand, DSM criteria are very researchers, and patients alike. Such an ap-
selective and will only allow diagnosing patients proach avoids the pitfalls of putting people into
with a particular symptom profile (Fink, 1996). distinct categories and provides information
In view of all these problems, Fava (1992b) that is directly useful for the design of clinical
suggests that the concept of abnormal illness interventions.
behavior should probably replace the somato-
form disorders rubric because it provides a more 6.24.4.1 Somatoform Disorders vs. General
useful conceptual framework for disorders that Medical Conditions
would otherwise be scattered and unrelated in
the DSM or that would not find a place at all. The presence of a general medical condition
Fink (1996) makes a similar point arguing that that could account for the presenting symptoms
researchers have been preoccupied with physical must be carefully examined and considered in
symptoms in search for reliable and valid every case where physical problems are the
diagnostic criteria for somatization, but have focus of a patient's complaints. Symptoms such
neglected the psychopathology, behavior, and as pain or fatigue may be related to a wide array
other aspects of the problem. A simplistic of problems ranging from normal sensations to
reliance upon physical symptoms is question- fatal diseases. Health professionals are very
much aware of the danger of misdiagnosing a physical symptoms and functional defects.
somatoform disorder and of missing the pre- Terms such as ªnonorganic . . .º should be
sence of actual physical problemsÐparticularly avoided completely.
diseases with a slow or diffuse onset such as
multiple sclerosis, brain tumors, or systemic
6.24.4.2 Differentiating Somatoform Disorders
lupus. Some patients diagnosed with somato-
form disorders or ªfunctional problemsº are Differentiating the various somatoform dis-
ultimately diagnosed with a demonstrable orders using DSM-IV criteria is difficult
medical condition and must be regarded as because criteria are vague and there is consider-
initial false-positives (for a particularly poign- able overlap of symptoms, Nonetheless, several
ant example, see Fishbain & Goldberg, 1991). distinctions can be made and are briefly
On the other hand, advances in medical discussed below.
diagnostic procedures (e.g., PET and magnetic
resonance imaging (MRI) scans) have resulted
in more accurate diagnostic decisions and 6.24.4.2.1 Somatization disorder vs.
reduced the number of false-positive diagnoses hypochondriasis
of somatization disorder (Kent, Tomasson, & In somatization disorder the patient's atten-
Coryell, 1995). tion is directed at the somatic symptoms
Any diagnosis of somatoform disorders themselves, whereas in hypochondriasis symp-
should be made with caution and only after toms are generally less elaborate and the patient
careful physical examination. This recommen- is concerned about a possible underlying illness
dation is also supported by the fact that it is (Murphy, 1990). As a result, hypochondriacal
occasionally difficult for physicians and psy- patients experience higher levels of anxiety,
chologists alike to determine the ªtrueº nature whereas patients with somatization disorder
of somatic complaints. In a study of 200 experience lower levels of anxiety or no anxiety
successive patients undergoing cardiac cathe- at all.
terization, it was found that neither standard
medical tests before catheterization nor stan-
dard psychological questionnaires alone were 6.24.4.2.2 Somatization disorder vs. pain
able to discriminate reliably chest pain patients disorder
with coronary artery disease from patients Although pain symptoms are included in the
without heart disease. Diagnostic accuracy only diagnostic criteria for somatization disorder,
improved when cardiac catheterization was symptoms other than pain must be present
considered along with results from psychologi- before a diagnosis can be assigned. In contrast,
cal assessments (Eifert, Edwards, Thompson, pain is the predominant (and frequently
Haddad, & Frazer, 1997). exclusive) focus of the clinical presentation of
In addition, there is at times a reciprocal a person with pain disorder.
relationship between health anxiety and somatic
symptoms. For instance, Salkovskis (1996)
6.24.4.2.3 Somatization disorder vs. conversion
describes how the very safety-seeking behaviors
disorder
designed to reduce anxiety frequently increase
the symptoms that are the focus of anxiety. He A key difference is the sheer number of
cites the example of patients who palpate or rub symptoms. A person with somatization dis-
lumps until they swell and cause pain. Several order, by definition, must report at least eight
authors also point to potential pathophysiolo- symptoms of four different types, whereas a
gical mechanisms that may underlie unex- person with conversion disorder typically
plained physical symptoms. Sharpe and Bass manifests only one symptom.
(1992) describe various pathophysiological
mechanisms in abdominal pain, chest pain,
6.24.4.2.4 Hypochondriasis vs. body dysmorphic
chronic fatigue, breathlessness, and irritable
disorder
bowel syndrome that can be detected by routine
or advanced medical evaluation. For instance, Although hypochondriasis and BDD share
symptoms can be due to excessive physiological some features (e.g., bodily preoccupation,
activity (e.g., smooth-muscle contraction, repetitious body checking, reassurance seeking,
striated-muscle contraction, changes in endo- and medical consultations), individuals engage
crine secretion and in blood flow) that may be in these behaviors for different reasons. Persons
accentuated by stress and intense emotions. with hypochondriasis are afraid of serious
Both in fairness to the patient, and to design the illness, whereas persons with BDD are con-
most appropriate intervention, we should be cerned about the physical appearance of their
careful in the use of such terms as unexplained body.
Problems of Differential Diagnosis and Comorbidity 551
6.24.4.3 Relation Between Somatoform regardless of whether the conviction is accom-

Disorders and Depression panied by fear or not.
A clear separation of the different dimensions
There is a high comorbidity of all somato- of hypochondriasis may contribute to a better
form disorders with depression and to a lesser understanding of such problems and result in
extent with dysthymic disorder. For instance, in more appropriate treatments. We view hypo-
a prospective study of 30 psychosomatic clinic chondriasis as a syndrome where persons
inpatients, Rief, Hiller, Geissner, and Fichter present with problems that fall on a continuum
(1995) found high lifetime comorbidity between along four dimensions.
various somatoform disorders and both depres- (i) Preoccupation with the body and its func-
sion (86%) and anxiety (43%). Remission rates tioning. Excessive awareness of and interest in
were higher when somatoform disorders were bodily sensations and functioning, with or
not accompanied by other psychiatric disorders without physical complaints, constitutes what
(e.g., anxiety, depression, or addiction) than in Starcevic (1988) aptly called ªthe hypochon-
cases with comorbidity. In addition, the pre- driacal core.º Such bodily preoccupation, espe-
sence of somatoform disorders increased the cially when coupled with somatic complaints,
risk for other psychiatric conditions (Rief et al.). may produce a state of somatic uncertainty and
Several studies found a striking relation be- form the basis for the other three dimensions of
tween pain and major depression or dysthymic the disorder.
disorder but the specifics of that relation remain (ii) Disease suspicion or conviction. The per-
elusive (Chaturvedi & Michael, 1986; France, son has the suspicion or is convinced of having a
Krishnan, Houpt, & Maltbie, 1984; Turk, serious physical disease; suspicion and convic-
Okifuji, & Scharff, 1995). tion are on a continuum of strength, and in rare
cases the conviction may reach delusional
6.24.4.4 From Differential Diagnosis to intensity.
Dimensional Classification (iii) Disease fear. The person fears having a
serious physical disease.
Despite considerable degree of overlap in the (iv) Safety-seeking behaviors. The function
symptoms of persons with hypochondriasis, of behavior such as repeated requests for
disease phobia, and panic disorder, also medical examinations and tests, bodily check-
reflected in reports of high comorbidity rates ing, verbal complaints, and seeking reassurance
(Warwick & Salkovskis, 1990), our under- is to reduce worry and anxiety over physical
standing of the relation between somatoform illness (Eifert, 1992; Salkovskis, 1996; Warwick
and anxiety disorders is poor (Barlow, 1988; & Salkovskis, 1990).
Forsyth & Eifert, 1998). In the following Although a person could score highly on any
discussion, we will adopt a dimensional one or all four dimensions, bodily preoccupa-
approach to understanding illness-related con- tion and disease suspicion/conviction are most
cerns that might be useful for both assessment central to hypochondriasis. As indicated, dis-
and treatment purposes. Delineating points of ease suspicion/conviction may or may not be
overlap and differences is also an important first accompanied by fear of the suspected disease.
step toward designing more thorough empirical Clinically, this feature is most apparent in
investigations of the subject. patient's resistance to medical reassurance.
For instance, Fava and Grandi (1991) indicated
that patients may continue to be extremely
6.24.4.4.1 Hypochondriasis and disease fear: a
worried about their health even though their
dimensional perspective
fear of suffering from a specific disease may be
According to Pilowsky's (1967) classic study, eliminated by a satisfactory medical examina-
hypochondriasis has three dimensions: disease tion. In other words, a patient's morbid pre-
phobia, disease conviction, and bodily preoccupation with disease may continue in the
occupation. These dimensions are still the basis absence of any specific disease phobia main-
for the current DSM criteria for hypochon- taining and prolonging a person's suffering and
driasis. Unfortunately, the DSM definition fails keeping them from consulting a psychologist.
to distinguish hypochondriasis as a fear of Disease phobia is a persistent unfounded fear
disease from a conviction of having a disease. of suffering from or contracting a disease
This failure could, at least in part, account for (Bianchi, 1973, Eifert, 1992) and may occur in
the ambiguity in the use of the diagnostic label the absence of a conviction or suspicion of
of hypochondriasis (cf. Eifert, 1992). Fear of having a disease. For example, a person may be
having a physical disease has quite different afraid of having a heart attack or contracting
theoretical, diagnostic, and therapeutic impli- cancer without being convinced or suspicious of
cations from a conviction of being seriously ill, having heart disease or cancer. According to
Fava and Grandi (1991), there are two main (ii) Modulation and timing of anxiety
clinical characteristics of disease phobia that
Fava and Grandi (1991) describe the relation
distinguish it from more general hypochon-
of disease phobia to hypochondriasis as similar
driasis. One feature is the specificity and
to that of panic disorder to generalized anxiety.
temporal stability of symptoms. For instance,
This perspective is based on a difference in the
it was found that most cardiophobic patients
modulation and timing of anxiety in disease
were only afraid of having a heart disease but
phobia and panic compared to hypochondriasis
not of other diseases (Eifert et al., 1996). Even
and generalized anxiety disorder. As in panic
over time, these patients are unlikely to develop
disorder, which is characterized by a sudden
fears focused on other organ systems. This
surge of aversive sensations and fear that tends
specificity led Marks (1987) to view disease
to subside within 30±45 minutes, persons with
phobias as a subtype of hypochondriasis
disease phobias tend to experience anxiety att-
focused on a specific illness. The second feature
acks of a relatively short duration when exposed
of disease fears is that they manifest themselves
to feared cues. In contrast, persons with primary
in cue-controlled attacks of shorter durations.
hypochondriasis experience more constant and
For example, a cardiophobic person's fear of
chronic levels of worry about body sensations
having a heart attack becomes salient and
and illness, similar to the chronic levels of worry
particularly strong only in response to the acute
found in generalized anxiety disorderÐ
experience of chest pain and heart palpitations
although in both disorders worries and fears
(Eifert 1992; Eifert et al. 1996). This feature of
may occasionally escalate into a ªcrescendo of
disease phobias is in contrast to the morbid
panicº (Salkovskis & Clarke, 1993; Warwick &
preoccupations of persons with primary hypo-
Salkovskis, 1990). In addition, these authors
chondriasis who constantly worry and ruminate
point out that persons with hypochondriasis
about their health.
typically judge the danger they fear to occur at
some distant time in the future, whereas panic
patients fear an imminent catastrophe.
6.24.4.4.2 Relation between hypochondriasis
and anxiety disorders
A discussion of the dimensions of excessive (iii) Misinterpreted symptoms and focus of fear
health anxiety raises several questions regarding In panic disorder as well as disease phobia,
the relation of this type of anxiety to other individuals misinterpret autonomic symptoms
anxiety-related problems, which will be dis- that are involved in acute anxiety attacks.
cussed next. Persons with disease fears, however, tend to
report fewer and less severe panic symptoms
(Beck, Berisford, Taegtmeyer, & Bennett, 1990)
(i) Comorbidity of disease phobias and hypo- and their fear is more specific and focused on
chondriasis with panic disorder one organ or organ system (Eifert, 1992; Eifert
Warwick and Salkovskis (1990) report that et al., 1996). Such individuals do not fear the
59% of hypochondriacal patients seen in their symptoms themselves but what they seem to
clinic also met DSM-III-R criteria for panic indicate (i.e., serious disease). On the other
disorder. Other studies (Beitman et al., 1987; hand, persons with panic disorder tend to fear
Eifert et al., 1996) found that between 25% and generalized uncontrollable aversive autonomic
50% of cardiology persons with heart-focused body sensations, that is, they fear the actual
anxiety also suffer from panic disorder. Panic bodily sensations (see Chambless & Graceley,
patients with agoraphobia have been shown to 1989). They also have fewer and less pro-
score as high as hypochondriacal patients in nounced illness behaviors and beliefs than
areas such as somatic preoccupation, disease persons with either disease phobias or hypo-
phobia, and illness conviction (Noyes, Reich, chondriasis (Eifert, Seville, Antony, Brown, &
Clancy, & O'Gorman, 1986). Following treat- Barlow, 1992). Hypochondriacal patients are
ment, significant reductions in hypochondriasis more likely to misinterpret symptoms which are
scores occurred in those panic patients who not subject to direct amplification such as
improved with treatment. Fava, Kellner, Zie- lumps, skin rashes, and blemishes (Salkovskis &
lezny, and Gurand (1988) also found that before Clark, 1993), and their fear is focused on these
treatment, patients with panic disorder and health/disease issues.
agoraphobia scored significantly higher on
several illness fear and behavior measures than
(iv) Behavioral avoidance
a group of healthy controls. Following the
successful treatment of panic, however, these Individuals with disease phobia typically
group differences had disappeared. cannot avoid the stimuli they fear (pain and
Contemporary Theoretical Perspectives 553
palpitations) and therefore attempt to avoid cognitive-behavioral concepts predominate

activities which they believe bring on the contemporary perspectives on somatoform
dreaded physical symptoms (Eifert et al., disorders, we will briefly discuss some of these
1996). They may also engage in a number of concepts. In terms of specific disorders, we will
behaviors that are designed to protect their concentrate on hypochondriasis and pain since
body or a specific organ that they are afraid of much of recent research has focused on these
damaging. Warwick and Salkovskis (1990) have problems.
identified another important difference between
hypochondriacal and panic patients in patterns
of escape and avoidance related to illness. 6.24.5.1 Dysfunctional Processes in the
Hypochondriacal patients have more time to Somatoform Disorders
prevent the anticipated disaster by seeking 6.24.5.1.1 Abnormal illness behavior
medical attention because the anticipated harm
is perceived as much less imminent. In contrast, Pilowsky (1993, p. 62) defined abnormal
panic patients are likely to be overwhelmed by illness behavior as the ªpersistence of a
the sudden surge of arousal and fear during a maladaptive mode of experiencing, perceiving,
panic attack and perceive leaving the situation evaluating, and responding to one's own health
and their future avoidance as their only option status, despite the fact that a doctor has
(Salkovskis, 1996). provided a lucid and accurate appraisal of the
In conclusion, we believe that a dimensional situation and management to be followed (if
classification system could help overcome the any), with opportunities for discussion, nego-
pitfalls of pigeon-holing individuals into exist- tiation and clarification, based on adequate
ing diagnostic categories. Identifying dimen- assessment of all relevant biological, psycholo-
sions that allow a classification of illness gical, social and cultural factors.º
behavior based on the function that such Abnormal illness behavior is not a diagnosis
behavior serves, rather than its topography, as such, but refers to the disagreement between
might lead to a better understanding and the doctor and patient about the sick role to
improved treatments of persons with somato- which the patient feels entitled (Pilowsky, 1993).
form problems. Apart from the number and Sharpe, Mayou, and Bass (1995) argued that the
type of physical complaints, some of these concept of abnormal illness behavior is not only
dimensions include the presence and extent of valuable for understanding patients with func-
preoccupation with body and health, symptom tional somatic symptoms but for understanding
misinterpretation, disease suspicion or convic- the behavioral aspects of all illness.
tion, disease fear, safety-seeking approach and
avoidance behavior, focus and modulation of
6.24.5.1.2 Perception and attention
worry and fear, and pathophysiological pro-
cesses. Barlow (1988) noted that classification of Cognitive processing of medical information
any disorder, whether dimensional or catego- as well as attention to and attribution of
rical, should reliably describe subgroups of symptoms are believed to be central features
symptoms or behaviors that are readily identifi- in all somatoform disorders. Pennebaker (1982)
able by independent observers on the basis of conducted various studies on the role of
operational definitions. There should also be attention in symptom perception and concluded
some clinical usefulness or value in identifying that the more salient a somatic symptom (and
these subgroups or dimensions such as predict- the lower the amount of external distraction),
ing specific response to treatment, course of the the more likely and more intense the original
disorder, and tailoring treatment (Eifert, 1996; symptom is perceived. An implication of this
Eifert, Evans, & McKendrick, 1990). We hope finding is that deficient external stimulation
that a dimensional analysis of somatoform may pave the way for an increased attention to
disorders will move us closer toward reaching somatic symptoms Pennebaker also demon-
that goal. strated that simply directing a person's atten-
tion to bodily sensations increases reports of
symptoms. Selective attention to internal sti-
6.24.5 CONTEMPORARY THEORETICAL muli could thus augment somatic concerns.
PERSPECTIVES Although attentional bias has been well
documented in individuals with anxiety dis-
Although some theoretical models have been orders showing that attention is biased towards
advanced in relation to the process of somatiza- threat-related stimuli (cf. MacLeod & Math-
tion (cf. Kellner, 1991), somatoform disorders ews, 1991), empirical evidence for this type of
are understudied and poorly understood (Bar- bias in somatoform disorders is mixed. Most
low, 1988; Hitchcock & Mathews, 1992). As studies have examined hypochondriacal patients
(Barsky et al., 1995; Tyrer, Lee, & Alexander, 6.24.5.2 Disorder-specific Theoretical Models
1980) or normal subjects with high scores on a
hypochondriasis scale (Hanback & Revelle, As indicated, cognitive-behavioral perspec-
1978; Hitchcock & Mathews, 1992). In a series tives and research have been helpful in provid-
of experiments, Hitchcock and Mathews were ing a fledgling basis for a better understanding
able to demonstrate enhanced registration and and treatment of persons with somatic pro-
availability of illness information. They also blems. Below we will focus on cognitive-
found that hypochondriacal subjects interpreted behavioral perspectives of hypochondriasis
ambiguous information as threatening, and pain as most recent research has dealt with
although this bias was applied equally to illness these problems.
and social ambiguity. By contrast, subjects did
not show a bias for making rapid automatic
6.24.5.2.1 Hypochondriasis
inferences about bodily sensations implying
illness. Hitchcock and Mathews rightly caution, Behavioral theories of excessive health anxi-
however, that it is unclear whether enhanced ety stipulate that internal cues which have been
perceptual sensitivity to illness cues is a cause or associated with threat and bodily harm (un-
consequence of hypochondriacal anxiety. conditioned stimuli) can serve as conditioned
A particular perceptual disturbance in body stimuli (Forsyth, Eifert, & Thompson, 1996;
image has been demonstrated in persons with Miller, 1977). In the presence of these stimuli,
BDD although the specific processes involved individuals will begin to exhibit conditioned
have not been studied in detail. Rosen (1995) responses such as anxious behavior and phy-
proposed an integrative formulation of BDD siological changes. Classically conditioned in-
linking processes such as thinking about the stances of hypochondriacal behavior can be
presumed abnormality in appearance with maintained through operant reinforcement.
behavioral features such as avoidance of social Somatic complaints may lead to attention,
situations, camouflaging, checking, and under- sympathy, and escape from or avoidance of
taking beauty remedies. Preoccupation with the undesirable tasks or situations. Such conse-
imagined defect is especially salient in social quences may reinforce symptom reporting and
situations and may take on delusional or other hypochondriacal behavior (Kellner,
obsessional qualities. 1985). If somatic complaints are ignored in
the patient's home, hypochondriacal behavior
in the presence of family and friends may be
extinguished, but it may also lead the patient to
6.24.5.1.3 Deficits in emotion processing
increase medical assistance-seeking in the hope
(alexithymia)
of receiving attention from a physician instead.
Alexithymia literally means ªno words for These are examples of contingency-shaped
feelings.º The concept refers to a hypothesized behavior, but observers may also learn to
communicative function of somatic symptoms. exhibit hypochondriacal behaviors through
Its key features are a relative constriction of the process of modeling (Craig, 1986) or rule-
emotional functioning, poverty of fantasy life, governed behavior (Hayes & Wilson, 1994).
and inability to find appropriate words to According to Kellner (1985), hypochondriacal
describe one's emotions (Taylor, Bagby, & behavior worsens as the conditioning process
Parker, 1991). Alexithymic individuals seem repeats.
to be vulnerable to mounting tension from As can be seen in Figure 1, cognitive theories
undifferentiated states of unpleasant emotional of health anxiety emphasize the role of
arousal. This vulnerability is presumably caused misinterpretations of innocuous bodily changes
by a disturbance in the processing of emotional or of information provided by doctors, friends,
awareness that is believed to interfere with the or the media. Patients focus on essentially
subject's ability to experience and express harmless physical sensations, which they con-
emotions. For example, in a sample of normal sistently misrepresent and misinterpret as
volunteers, Vingerhoets, Van Heck, Grim, and indications of physical illness (Barsky & Kler-
Bermond (1995) found strong negative correla- man, 1983; Warwick & Salkovskis, 1990). As a
tions between alexithymia and the expression of result, symptoms and medical information tend
emotions, daydreams, and fantasies, and plan- to be perceived as more dangerous than they
ful and rational actions. Bach and Bach (1995) really are and a particular illness is believed to be
found high alexithymia scores to be predictive of more probable than it really is (Salkovskis,
persistent somatization. More recently, the 1996). According to Salkovskis, the onset and
concept of alexithymia has also been discussed maintenance of health anxiety involves the
in relation to a variety of psychological complex interaction of several factors. Previous
traumata (Salminen, SaarijaÈvi, & AÈaÈrelaÈ, 1995). experiences and perception of illness in self and
Contemporary Theoretical Perspectives 555
POTENTIALLY THREATENING STIMULI

bodily variations, medical information
PAST LEARNING
past experiences, consequences, and perceptions of illness
in self and others; medical (mis)management
APPRAISAL OF THREAT AND COPING SKILLS/

BELIEFS ABOUT BEING ILL
probability, outcome, cost-benefits, coping resources
SAFETY-SEEKING INCREASED AROUSAL/ MOOD CHANGES

BEHAVIOR PHYSIOLOGICAL anxiety, depression
reassurance seeking, body CHANGES
checking, activity avoidance,
self-imposed restrictions
Figure 1 Cognitive-behavioral model of maladaptive illness-related behavior (adapted from Warwick &
Salkovskis, 1990, and Salkovskis, 1996; cf. Eifert, 1992).
others (`whenever I had physical symptoms as a future pain behavior is subject to selection by
child I was taken to the doctorº) are often the consequences. Verbal reports and nonverbal
root of future hypochondriacal behavior and expressions of pain are maintained because of
may result in the formation of dysfunctional the associated delivery of positive and negative
beliefs (`bodily symptoms are always a sign that reinforcers. As indicated, pain behavior may be
something is wrongº). As a result, harmless positively reinforced through tangible benefits,
incidents or physical symptoms activate these attention, or stimulation (i.e., concern or
negative assumptions and other catastrophic sympathy). Pain behavior may also be nega-
thoughts (`this is going to get worseº), which in tively reinforced when it results in the avoidance
turn lead to behavior changes such as increased of or escape from undesirable activities or
safety-seeking and avoidance as well as heigh- stimulation such as work or unwanted sexual
tened physiological arousal, anxiety, and de- encounters. In the absence of direct exposure to
pression. Repeated cycles of this kind may lead the environmental contingencies, these beha-
to an exacerbation of hypochondriacal symp- viors may be acquired or taught through
toms and perceptions of oneself as a sick and modeling (Craig, 1986). Respondent and oper-
incapable individual (Salkovskis, 1996). ant conditioning may interact in the onset and
maintenance of pain behavior (Rachlin, 1985).
For instance, the avoidance of physical activity
can lead to muscle fibers shortening and losing
6.24.5.2.2 Pain
elasticity. This can be quite painful and, as a
According to the behavioral theory of pain consequence, persons tend to avoid or escape
developed by Fordyce (1976), pain behavior is from physical activity. Such avoidance and
often acquired through respondent condition- escape are negatively reinforced when they lead
ing (ªsensory painº) and maintained through to a short-term decrease of pain, but avoidance
operant conditioning (ªpsychological painº). and escape may also result in long-term cost by
Initially, pain is considered to be an overt exacerbating the physical condition of the
reflexive response to an antecedent noxious individual and lead to a vicious circle (Flor
stimulus such as an injury. Following onset, et al., 1990). A number of studies have shown
that pain behavior is susceptible to social pain and associated mood states (Turk et al.,
reinforcement. For example, Cairns and Pasino 1995). Our own research specifically supports
(1977) reported that exercise behavior increased the importance of perceived competence for
when praise was delivered contingently and coping with chronic pain, indicating that
decreased soon after praise delivery was perceived competence determines how intense
discontinued. Moreover, pain patients who persons experience pain, how much they are
perceived their wives as solicitous exhibited disturbed by it, and whether they engage in
more pain behavior in the presence of their adaptive or maladaptive coping behavior
wives than patients who perceived their wives as (Schermelleh-Engel et al.). Although the coping
nonsolicitous (Flor, Kerns, & Turk, 1987). process is not systematically affected by the
Although pain is a subjective phenomenon characteristics of the pain stimulus, a person's
and difficult to quantify, behavioral researchers type of coping behavior affects the impact of the
have attempted to quantify pain behavior. In a pain stimulus (cf. Asmundson & Norton, 1995).
choice situation, the relative frequency of Using path analytic structural equation model-
responding (either the number of responses or ing, we found that coping behavior is directly
the amount of time responding) allocated to a influenced by a person's perceived level of
particular alternative closely approximates the competence and only indirectly affected by pain
relative frequency of obtained reinforcement for intensity and pain-related anxiety and depres-
that alternative. This relation is called the sion. Decreasing competence appears to lead to
matching law (Baum, 1974; Herrnstein, 1970). increasing pain intensity and increasing pain
Applied to pain, the matching law suggests that emotions, which, in turn, increase maladaptive
the frequency of an individual's adaptive behavior. Conversely, individuals who trust in
behavior (e.g., pain coping without complain- their abilities to cope adequately with pain are
ing), compared to maladaptive pain behavior more likely to engage in adaptive behavior,
(e.g., verbal complaints, facial contortions), will irrespective of how anxious they are; such
match the relative frequency of reinforcement persons also do not suffer as much as individuals
obtained for each type of behavior. In other with low perceived competence.
words, if maladaptive pain behavior is rein-
forced more than adaptive behavior, the like-
lihood of future maladaptive behavior will 6.24.5.3 Future Challenge: Integrative
increase, whereas adaptive pain coping behavior Biobehavioral Theories
becomes less likely. Conversely, if a patient's
maladaptive behavior is reinforced less than Throughout this chapter we have alluded to
adaptive pain behavior, preference will shift to the significant degree of overlap between
adaptive pain behavior. The matching law is somatization, hypochondriasis, and pain. Com-
clinically useful because it allows us to quantify prehensive theoretical accounts are just begin-
how much reinforcement will be necessary to ning to emerge for these problems, but they are
sustain a particular level of a given behavior. impeded by a relative lack of agreement on what
Fernandez and McDowell (1995) found the precisely somatization refers to. For instance,
matching law to provide accurate descriptions do persons diagnosed with ªunexplained phy-
of pain behavior. Although there are no other sical symptomsº (e.g., Speckens et al., 1996)
studies applying the matching law to pain, the suffer from somatization disorder, hypochon-
clinical utility of the matching law has been driasis, or are they a mix between the two?
demonstrated in the study of self-injurious Moreover, presenting with unexplained physi-
behavior (McDowell, 1981, 1982), social beha- cal symptoms does not imply that there is no
vior (Conger & Killeen, 1974), and disruptive medical or other explanation for the symptoms.
behavior of mentally retarded children (Mar- In some (although certainly not all) cases, an
tens & Houk, 1989). The matching law could explanation might be found if more sophisti-
provide a promising, more objective approach cated tests such as MRI or PET scans were
to quantifying pain behavior. conducted. Moreover, there is a significant
Cognitive-behavioral perspectives emphasize ªgray areaº that medical colleagues often refer
that maladaptive pain behavior is due to to when they speak of persons who do have
negative or unrealistically high expectations some degree of demonstrable pathophysiology.
about experiencing pain as well as low levels of Yet patient symptom reports, or their response
perceived competence to deal with pain to symptoms, seem to be ªexaggeratedº in view
(Schermelleh-Engel, Eifert, Moosbrugger, & of the degree of actual tissue damage or other
Frank, 1997). Apart from the physical char- physical changes. Since neither physicians nor
acteristics of the pain stimulus, or the amount of psychologists can adequately pinpoint or under-
tissue damage, differences in coping style are stand the symptoms and behavior of such
particularly important for the perception of patients from their respective perspective alone,
Treatment of Somatoform Disorders 557
these patients should be approached from a increase the sensitivity of chemo-nociceptors,

multidisciplinary perspective. Unfortunately, the likelihood of future pain also increases. This
theories that attempt to integrate biological/ feedback circle, in particular, nicely illustrates
medical with psychological knowledge are rare. the interplay between physiological and psy-
A notable exception is the psychobiological chological processes and helps us understand
account of chronic pain, which we will briefly how both physiological changes and the
summarize as an example of what more person's response to such changes may interact
adequate theories for persons with somatic to create the problems that persons with chronic
problems might look like in the future. pain struggle with.
The early physiological views of pain re-
garded pain simply as a sensation resulting from
patterns of stimulation from free nerve endings; 6.24.6 TREATMENT OF SOMATOFORM
pain intensity was believed to be directly pro- DISORDERS
portional to the amount of peripheral nocicep-
tive input related to tissue damage (Dallenbach, Psychologically distressed medical patients
1939). Proposed by Melzack and Wall (1965), who present with unexplained somatic symp-
the gate control theory (GCT) was one of the toms are high users of care and their doctors
first psychophysiological theories to challenge regard them as frustrating and difficult to treat
this assertion. According to the GCT, pain is due (Mayou & Sharpe, 1995). There is often a
to the complex interplay of receptors, afferent mismatch between the expectations of these
and efferent processes, and spinal and suprasp- patients and their doctors' abilities and com-
inal processes. More recent theories (cf. Cailliet, munication skills. For instance, Eifert (1992)
1993) have expanded the basic concepts of the pointed out that diagnoses such as functional
GCT to relate current information on physio- heart problem, nervous heart, atypical chest
logical processes (e.g., the role of acid metabo- pain, and pseudoangina can be easily misinter-
lites and opiate receptors) to psychological preted by a cardiophobic patient who is
factors. An integrative psychobiological theory determined to believe that some significant
of chronic pain proposed by Flor et al. (1990) cardiac disease is being described. As a result,
relates concepts and findings from areas such healthcare providers often feel frustrated and
operant, respondent, observational, and cogni- emotionally drained because these patients are
tive learning and relates them to biological obviously in need of psychological support but
concepts and physiological findings. resent being referred to a psychologist or
Flor et al. (1990) propose that pain is psychiatrist. Owing to the overlapping psycho-
a complex response that comprises subjective- logical processes involved in the various
psychological, motor-behavioral, and physio- somatoform disorders, we will first outline
logical-organic components. Stress may treatment recommendations that are applicable
precipitate and facilitate a particular pain to most individuals with any of the somatoform
disorder to which the individual is already disorders. This discussion will be followed by
predisposed on an unlearned or learned basis. some specific recommendations and outcome
The learned aspect of this predisposition data for individual disorders.
consists of a reduced threshold for nociceptive Patients often perceive the use of diagnostic
activation due to previous trauma or social labels such as hypochondriasis as an insult
learning experiences resulting in a physiological because these labels are seen to imply that
response stereotypy of a specific body system or patient problems are not real and are ªjust in
group of muscles. Stress and pain episodes may their head.º Accepting and understanding the
trigger a host of autonomic and muscular symptoms rather than refuting or arguing with
reactions, particularly sympathetic activation the patient is therefore the most important
and elevated muscle tension levels. If stress or condition for engaging the patient in a
pain-related muscular contractions occur re- therapeutic working relationship (cf. Bass &
peatedly, a number of muscular and sympa- Benjamin, 1993). In the engagement stage of
thetic reflexes lead to increases in muscle tension treatment, patients are helped to see that there
and to sympathetically mediated vasoconstric- may be an alternative explanation for the
tion. If the muscular contractions are of difficulties they are experiencing (Salkovskis,
sufficient intensity, frequency, and duration, 1996). For instance, although chest pain can be
there will not be sufficient blood and oxygen in due to coronary artery disease, it can also be
the affected muscles and algogenic (pain- caused by hyperventilation-induced chest wall
inducing) substances will be released. The muscle tension (Eifert, 1992). The general
ensuing pain experience increases muscular treatment strategy is to test such alternative
and sympathetic hyperactivity and may thus nonmedical or benign medical explanations for
lead to a vicious circle. As these processes also symptoms and to conduct therapy in the context
of an experiment that provides an opportunity deemed to be of primary importance. Most

for testing alternative hypotheses (Salkovskis, somatization patients have distinct expectations
1996). regarding treatment goals and procedures and
Rather than merely telling patients there is no try to persuade their doctors to follow their
ªorganicº reason for their chest pain, an wishes for further medical investigations and
explanation of symptoms that overcomes the treatments. Bass and Murphy (1990) state that
nonorganic±organic dualism provides the pa- treatment often involves long-term supportive
tient with a more acceptable rationale and psychotherapy and must be directed toward
reassurance. For instance, to provide a patient controlling the demands on medical care as well
with a credible explanation of how anxiety and as the treatment of symptoms and social
chest wall muscle tension can result in chest disability. These authors recommend the fol-
pain, patients may be given a chest-focused lowing five steps: (i) establish a diagnosis by
relaxation with EMG feedback that literally collecting appropriate medical and psychosocial
shows them how they can change their chest information; (ii) encourage a long-term suppor-
tension levels (Eifert, 1996). Salkovskis and tive relationship with only one understanding
Warwick (1986) found that reassurance which primary care physician to prevent doctor-
only informs the patients that there is nothing shopping and to coordinate all actions; (iii)
organically wrong with their body will actually see patients on regular appointments rather
increase future reassurance-seeking rather than than on demand to prevent reinforcement of
decrease it. On the other hand, appropriate illness behavior; (iv) regard the patient's
reassurance and feedback that provides the physical complaints as a form of communica-
patient with new and alternative explanations is tion rather than as evidence of disease; and (v)
the key to successful treatment, and in some minimize the use of psychotropic drugs and/or
cases, may help prevent the development of analgesic medication. In general, adaptive
chronic somatization problems in the first place. behavior is encouraged and promoted, whereas
It is therefore important that medical profes- sick role behavior is ignored as much as
sionals are trained to deal with patients in this possible. A study by Smith, Monson, and Ray
manner. For example, Goldberg, Gask, and (1986) found that such a treatment program did
O'Dowd (1989) developed a training program not lead to improvements on any of the
for primary care physicians that included measures of mental, physical, or social health,
making patients feel understood by carefully but patient healthcare was less costly. In
listening to their complaints and symptoms, contrast, Krasner, Rost, Cohen, Anderson,
changing the agenda of the actions to be and Smith (1995) demonstrated that eight
undertaken from a somato-medical focus on sessions of brief group therapy improved
bodily symptoms to a psychological perspective physical and mental health at one year follow-
focusing on emotional distress. Physicians were up. Treatment focused on coping with the
also taught how to help patients reattribute nature and consequences of the physical
bodily symptoms by linking them to psycholo- symptoms, general problem-solving, and help-
gical factors. ing patients take more control of their lives.
Another important treatment strategy is A randomized controlled trial examining a
withholding unnecessary medication and med- comprehensive cognitive-behavioral approach
ical examinations (response prevention for for medically unexplained physical symptoms
safety-seeking behaviors). A symptom diary is was conducted by Speckens et al. (1996). This
used to get a prospective, rather than retro- team compared a cognitive-behavioral inter-
spective, view of the symptoms' course, invention group of 39 general medical outpatients
tensity, and relation to life stresses. Rief (1996) with a control group of 40 patients receiving
suggests starting off with a symptom-oriented optimized medical care. The 6±16 sessions of
treatment and, in the second phase of therapy, cognitive-behavioral therapy included (i) ima-
shifting towards more general goals, such as ginary exposure and distraction techniques to
occupational problem-solving, social skills break the vicious circles of cognitive avoidance
training, and quality of life enhancement. and preoccupation; (ii) activity scheduling,
exposure in vivo, and response prevention to
decrease avoidance behavior; (iii) relaxation
6.24.6.1 Somatization Disorder training, breathing exercises, and physical
exercises; and (iv) problem-solving or social
Most articles refer to the management rather skills training to overcome any problems in
than to the treatment of patients with persistent interpersonal relationships. At both 6 and 12
somatic problems (e.g., Bass & Benjamin, 1993). month follow-ups, compared to the control
Early diagnosis and the prevention of unneces- group, the intervention group reported lower
sary medical and surgical investigation are intensity and frequency of symptoms, reduced
Treatment of Somatoform Disorders 559
illness behavior, less sleep impairment, and tions with others) should begin to maintain
fewer limitations in social and leisure activities. behavior and the frequency and magnitude of
artificial reinforcement can be slowly reduced.
Salkovskis and Warwick (1986) reported two
6.24.6.2 Hypochondriasis successfully treated single cases of primary
hypochondriasis using cognitive-behavioral
Traditionally, individuals with hypochon- methods. In another study, Visser and Bouman
driasis were considered difficult to treat and (1992) found that four of six hypochondriacal
their prognosis was regarded as poor. For patients improved significantly following in vivo
instance, early studies assessing the effectiveness exposure, response suppression, and cognitive
of a variety of psychological interventions therapy. Interestingly, in this small study,
available at that time (e.g., Kenyon, 1964) exposure and response suppression (behavioral
found 40% of patients with primary hypochon- components) appeared to have accounted for
driasis to be unchanged or worse following more of the improvement than the cognitive
treatment. Although patients with unexplained component they used. The positive results of
physical symptoms and/or health anxiety still these series of single case studies were supported
pose a considerable challenge for therapists, in a first controlled trial that showed cognitive-
cognitive-behavioral interventions have yielded behavioral therapy to be superior to a wait-list
encouraging results. control condition (Warwick, Clark, Cobb, &
The first comprehensive cognitive-behavioral Salkovskis, 1996).
treatment formulations were provided by War- For patients whose main hypochondriacal
wick and Salkovskis (1990). Patients are concerns involve disease or illness phobia
instructed to self-monitor during hypochon- without significant conviction of having the
driacal episodes, paying careful attention to illness, a more focused program of tension
environmental events, physical symptoms, as- reduction (e.g., through relaxation), exposure to
sociated cognitions, and their resulting hypo- the feared stimuli, and prevention of checking
chondriacal behavior. As indicated, their and safety-seeking can be sufficient (Eifert,
treatment is directed at evaluating alternative, 1992, 1996). A representative example of this
nonthreatening explanations of body-related type of program was implemented by Warwick
observations that patients misinterpret as signs and Marks (1988). Their treatment employed
of serious disease. Two possible explanations exposure to feared stimuli, paradox (deliberate
for the patient's problem are considered along- attempts to induce a panic attack), and response
side each other rather than as mutually exclusive prevention such as banning reassurance-seeking
alternatives (Salkovskis, 1996). Patients are and physician visits. There was a significant
then asked to engage in a variety of behavioral decrease in illness fear and increase in work and
experiments to test these new explanations and social adjustment for the group of 17 patients
therapy proceeds as an evaluation of the relative who were treated.
merits of the alternative views. Salkovskis Overall, cognitive-behavioral treatments are
emphasizes that inappropriate safety-seeking very promising and prognosis for patients
prevents individuals from discovering that their treated with such interventions seems more
fears are groundless. Hence, the key function of favorable than previously thought. More ex-
exposure exercises and response prevention is to tensive and controlled studies are needed to
allow patients to repeatedly experience feared examine what the most crucial treatment
bodily sensations to disconfirm fears. Thereby components are and to determine the mechan-
patients learn that the things they are afraid of isms for their success.
do not actually happen or that consequences are
not as bad as they expected.
A system of differential reinforcement may 6.24.6.3 Pain Disorder
need to be added for individuals who gain
sympathy or interest for physical complaints Although there have been suggestions that
but may receive little attention otherwise. In treatment of pain based on psychodynamic
those cases, family members and other indivi- principles may be effective (Adler, Zlot, Hurny,
duals the patient has contact with (including the & Minder, 1989), empirical evidence has been
therapist) should reinforce patient initiation of scarce and not very compelling (Gamsa, 1994;
conversation on any topic other than symptoms Turk et al., 1983). Biofeedback (e.g., Budzynski,
(healthy conversation). This reinforcement Stoyva, Adler, & Mullaney, 1973) and hypnosis
could consist of praise or increased attention. (Sacerdote, 1970) used to be popular treatments
As the patient engages in more healthy for pain, in the 1970s in particular. These
conversation, the natural contingencies (e.g., approaches, however, have been harshly criti-
reduced medical bills, more pleasant interac- cized on a number of grounds (for a review, see
Turk et al.). Most importantly, critics claim that Psychological Procedures (Chambless, 1995), it
these techniques are ineffective when used is unclear which specific methods are most
alone, and any treatment effects are due to effective. In a review of the experimental
the unwitting inclusion of behavioral and literature, Turk et al. (1983) concluded that
cognitive treatment components (Turk et al.) patients successfully use cognitive strategies, but
We will therefore focus on cognitive-behavioral the data ªdo not convincingly establish the
approaches to the management of pain. efficacy of any cognitive coping strategy relative
According to operant principles, pain beha- to the strategies that subjects bring to experi-
vior is not an expression or side effect of a pain ments, nor is there sufficient evidence to support
problem, instead it is the problem (Rachlin, the use of any one strategy compared to any one
1985). Therefore, the goal of treatment is to otherº (p. 96). Others have raised more
extinguish maladaptive pain behavior and to fundamental criticisms and argued that the
teach and encourage the use of more adaptive effects attributed to direct cognitive manipula-
pain coping strategies (Nicholas, Wilson, & tions could be due to associated environmental
Goyen, 1991). Treatment begins with a thor- manipulations (Rachlin, 1985).
ough functional analysis of current pain
behavior and the environmental contingencies
associated with that behavior. Once the con- 6.24.6.4 Conversion Disorder
sequences maintaining the maladaptive pain
An important first step in the treatment of
behavior are determined, attempts are made to
conversion symptoms is their early recognition
reduce reinforcement for that behavior and to
in which a physical examination plays a crucial
increase reinforcement for adaptive pain-coping
role. In many cases, a positive diagnosis can be
behavior (cf. Fordyce, Roberts, & Sternbach,
made on the basis of the rather atypical or
1985).
bizarre symptoms. Since conversion symptoms
In addition to changing a patient's maladap-
vary widely across patients, treatment needs to
tive pain behavior, cognitive-behavioral therapy
be individualized. Identifying precipitating
also attempts to alter associated thought
stressors is an important treatment strategy
patterns and the patient's perceived competence
so that patients can be taught more adaptive
to deal with pain (Schermelleh-Engel et al.,
ways of coping with these stressors. Occasion-
1997). Pain management programs typically
ally, manipulation of the patient's social
include: (i) decreasing demoralization through
environmental is necessary to reduce the
problem reconceptualization; (ii) enhancing
influence of secondary gain. Partners and
outcome efficacy by motivating active patient
significant others may have to learn how to
participation; (iii) fostering a patient's real and
reinforce the patient's nonsymptomatic beha-
perceived competence to deal with pain; (iv)
vior. Favorable prognosis seems to be related to
breaking maladaptive behavior and thought
acute onset, massive stressor, and a good
patterns; (v) teaching skills and adaptive
premorbid psychological and medical condition
responses to problems; (vi) teaching self-
(Kent et al., 1995).
attribution for change and success; and (vi)
planning maintenance.
Cognitive methods involving imagery and 6.24.6.5 Body Dysmorphic Disorder
distraction have often been added to pain
management programs (Turk et al., 1983). Behavioral interventions for BDD aim at
Based on the assumption that pain is mediated changing avoidance behaviors, reassurance-
by thoughts and images, patients are encour- seeking, checking, and excessive grooming.
aged to create and focus on those thoughts and Exposure in vivo is used to counter avoidance
images that alleviate pain, while ignoring those of social situations (meeting people, having a
that exacerbate pain. Particularly for patients conversation, being in the spotlight), body
who engage in few activities, behavioral dis- image situations (wearing camouflaging cloth-
traction may be beneficial in more than one way. ing such as baggy pants, long hair, sunglasses).
This technique involves the introduction of Patients are encouraged to expose themselves
overt activities that require attention in order to to social situations, rather than avoiding them
be performed (i.e., hobbies). As clients continue and to observe the reactions of other people to
with these activities, they frequently recognize their imagined deformity. Rosen (1995) sug-
the value of the activities beyond their role as gests exposure assignments such as wearing
distractors. trendy clothes, using make-up to accentuate
Although the cognitive-behavioral approach features, standing closer to people, undressing
to pain management has been identified as an in front of one's spouse. Response prevention
empirically validated treatment by the Task may involve stopping looking in the mirror for
Force on Promotion and Dissemination of excessive periods of time and refraining from
Conclusions 561
the use of make-up and from inspecting skin the unsatisfactory and somewhat arbitrary
blemishes. current DSM classification. We have noted a
There are few controlled treatment outcome considerable degree of phenomenological and
studies for BDD, but several case studies and functional overlap in the problems of persons
uncontrolled trials have been reported that have diagnosed with somatization disorder, hypo-
used systematic desensitization (e.g., Munjack, chondriasis, and chronic pain disorder as well
1978), exposure and response prevention (Ne- as overlap between somatoform and anxiety
ziroglu & Yaryura-Tobias, 1993), and social disorders. In fact, comorbidity of somatoform
skills training (Braddock, 1982). Schmidt and disorders with an anxiety disorder, depression,
Harrington (1995) describe a successful and general medical conditions are the rule
cognitive-behavioral therapy in a 24-year-old rather than the exception. In view of the
male who was preoccupied with having small existing conceptual and diagnostic confusion,
hands. Nine one-hour sessions with behavioral vagueness, and imprecision, we question not
experiments aimed at challenging beliefs about only the utility of the current criteria for and
size of his own hands and other people's distinctions between somatoform disorders but
attention to his hands. Treatment resulted in also the wisdom of keeping hypochondriasis in
a decrease of BDD-related cognitions, distress particular in a section separate from the anxiety
and avoidance behaviors, as well as a decrease in disorders.
Beck Depression and Beck Anxiety Inventory Difficulty in relating the physical and psy-
scores. chological aspects of somatoform disorders has
Recently, a first controlled study (Rosen, led to further confusion. Although we caution
Reiter, & Orosan, 1995) compared the effec- against an over-reliance upon medical diagnos-
tiveness of cognitive-behavioral therapy with a tic procedures and the explanatory power of
wait-list control condition in 54 female BDD current medical theory, diagnoses of the
patients. Treatment was conducted in small somatoform disorders are based upon the
groups and encompassed eight two-hour ses- sophistication and accuracy of medical diag-
sions. Therapy was aimed at modifying nostic procedures. Research and service delivery
dysfunctional thoughts about the patients' for patients would benefit from a more balanced
body image, the reduction of appearance- approach that is not just focused on finding or
checking, and exposure to avoided situations. excluding somatic abnormalities but one that
Results at post-test and four month follow-up combines current medical knowledge and
indicated improvement in the active treatment assessment techniques with assessments of a
condition on several measures of body image, patient's behavior, cognitive processes, and
whereas no such changes occurred in the social relationships (cf. Fink, 1996). In our
control condition. Although the results of this work with cardiac patients (Eifert et al., 1997)
study are promising, more controlled studies we observed how a simple reliance on one
are needed to corroborate existing data and to source of information (medical or psychologi-
examine the role of the various treatment cal) was inadequate for many patients. Instead,
components. it was the combination of sophisticated medical
tests and psychological information that yielded
the type of knowledge that was useful for
6.24.7 CONCLUSIONS recommending and designing the most appro-
priate treatment for the individual patient.
Unexplained and unexplainable somatic Hence, one of the most compelling conclu-
symptoms are very common in the general sions arising from this chapter is that somato-
population. These problems are costly to the form disorders cannot be adequately
individuals concerned in terms of distress and understood, assessed, and treated from a single
financial expense as well as to society in terms of perspective. Both the DSM classification system
lost productivity and healthcare costs. Com- as well as research in the area could be improved
pared with other common psychological dys- by adopting a multidisciplinary approach and
functions (e.g., anxiety and depression), our an integrated biopsychosocial perspective. For
present conceptual understanding of the soma- example, Mayou, Bass, and Sharpe (1995)
toform disorders is poor and satisfactory propose a multidimensional classification of
comprehensive models are still lacking. More- patients with functional somatic symptoms
over, for most of these disorders we do not have along five dimensions: (i) number and type of
basic and reliable information on issues such as somatic symptoms, (ii) mental state (mood and
prevalence, gender differences, etiology, and psychiatric disorder), (iii) cognitions (e.g.,
treatment outcome. symptom misinterpretations, disease convic-
One factor that has impeded a better tion), (iv) behavioral and functional impairment
understanding of the somatoform disorders is (illness behavior, avoidance, use of health
services), and (v) pathophysiological distur- 6.24.8 REFERENCES

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6.25
The Treatment of Substance
Abuse and Dependence
ROBIN J. DAVIDSON
Belvoir Park Hospital, Belfast, UK

6.25.1.1 Scope of the Problem 568
6.25.1.2 A Longitudinal Perspective 569
6.25.1.3 Assessment 570
6.25.2 THE STAGES OF CHANGE 571
6.25.3 PSYCHOLOGICALLY BASED TREATMENT METHODS 573
6.25.3.1 Motivational Interviewing 573
6.25.3.2 Behavioral Interventions 574
6.25.3.3 Relapse Prevention 575
6.25.3.4 Psychosocial Interventions 578
6.25.4 ISSUES IN TREATMENT 579
6.25.4.1 Treatment Intensity 580
6.25.4.2 Treatment Matching 580
6.25.1 INTRODUCTION forming one axis, the other being alcohol-

related consequences or disabilities. The ele-
The use of substances that alter mood, ments first proposed for the alcohol dependence
behavior, or cognitions has been a part of syndrome provide a framework for the descrip-
human life across numerous social contexts tion of psycho-active substance dependence in
throughout history. Invariably, there are some both major diagnostic systems.
individuals whose use of such substances may Dependence was seen by Edwards and Goss
lead to abuse and eventual psychological, social, as a cluster of behavioral, cognitive, and
or physical harm. The fourth edition of the physiological phenomena which develop after
Diagnostic and statistical manual of mental repeated use of alcohol. The elements were
disorders (DSM-IV; American Psychiatric As- persistent use in the light of harmful circum-
sociation, 1994) and the 10th edition of the stances, increasing salience of alcohol-seeking
International classification of diseases (ICD-10, behavior, narrowing of drinking repertoire,
World Health Organization, 1992) criteria for difficulties in controlling intake, relief use,
substance dependence owe much to the original and neuroadaptive changes producing tolerance
description of the alcohol dependence syndrome and withdrawal symptomatology.
(Edwards & Goss, 1976). These authors The ICD-10 criteria for substance depen-
proposed a biaxial concept with dependence dence are outlined in Table 1. Most of the
567
568 The Treatment of Substance Abuse and Dependence
components of dependence in ICD-10 are to be 1985, alcohol sales have declined slightly
found in DSM-IV and Hasin, Li, McCloud, and (Anderson, 1997).
Endicott (1996) report excellent agreement Since 1973 alcohol consumption in Europe
between the two systems. One problem, how- has decreased from a pure alcohol equivalent,
ever, with any diagnosis of psychoactive sub- annual, per capita intake of 14 litres to 10.4 litres
stance dependence is that it gives the impression (Gual & Colom, 1997). Consumption has since
of an all or none classification. This is not the stabilized and alcohol abuse continues to be a
case as there is continuous variation within all significant drain on economic resources. For
the elements, and so dependence should be seen example, it has recently been estimated that the
as a continuum ranging from mild to severe. total cost of the alcohol problem to the US
Mild dependence on alcohol could, for example, economy is $70 billion per annum. For every $1
be regarded as a statistically normal condition. collected in taxes about $7 are spent on
Nonetheless, the dependence syndromes as problems arising from alcohol abuse. Alcohol
defined in the two major diagnostic classifica- continues to be the major drug of abuse within
tions are robust and there is a body of factor the USA, where there are 18 million alcoholics
analytic evidence that indicates that the ele- compared with five million addicted to all other
ments form a single dimension, thus emphasiz- drugs combined (Asbury, 1995). Gelder, Gath,
ing the homogeneity of the syndrome Mayou, and Cowen (1996) outline the results of
(Davidson, Bunting, & Raistrick, 1989; Fein- two major US surveys which suggest a one year
gold & Rounsaville, 1995). This latter study also prevalence rate for alcohol abuse and depen-
confirms that the dependence syndrome, as dence of 7±10% with a lifetime risk of around
measured by DSM-IV diagnostic criteria, is 14±20%.
factorially distinct from measures of the con- Ramsey and Percy (1997) summarize the UK
sequences of substance abuse in all drug groups. prevalence literature on drug use rather than
In other words, some people use drugs safely. abuse or dependence among the 16±29 year age
Others, who may or may not develop symptoms group. In summary, about one-half of this
of dependence, abuse drugs and encounter group report using a prohibited drug ever,
problems. around one quarter in the last year, and 14% in
Thus drug abuse and its debilitating sequelae the last month. In the surveys, it was estimated
are not necessarily synonymous with depen- that 1% of respondents used heroin at some
dence. Abuse has been defined by the Royal point in their lives. More direct approaches
College of Psychiatrists (1979) as the use of a suggest that opiate use among the general, inner
substance that ªharms or threatens to harm the city population in London is around 2%. The
physical or mental health or social well-being of Natural Comorbidity Survey in the USA
an individual.º Harmful consequences can arise (Kessler, McGonagle, & Zhao, 1994) found
from prolonged and excessive drug use, but can that one year prevalence for drug dependence
equally occur as a result of acute intoxication in for all adults was 3.6% while lifetime prevalence
an occasional user, or indeed can be associated was 11.9%. Just under 40% in the US sample
with the mode of administration of the drug. report using at least one illicit drug in their
For example the recreational use of ecstasy at a lifetime. It must be acknowledged that there is a
Saturday night dance can have fatal conse- range of prevalence estimation methodologies,
quences, and HIV infection is not restricted to which can render rather different estimates and
severely dependent, long-term abusers. This which have been critically evaluated by Sutton
chapter will focus primarily on the treatment of and Maynard (1992).
addictive behavior itself, rather than the harm- Rather than detail the extent and pattern of
ful consequences associated with drug and use for each substance for different groups of
alcohol abuse. people, some of the problems faced by epide-
miologists in this field will be outlined using
cocaine by way of illustration. One can measure
6.25.1.1 Scope of the Problem population use of a drug in terms of quantity
and frequency, or the extent of drug dependence
The extent and demography of substance use or alternatively drug-related problems, such as
is constantly changing. However, Babor (1994) physical illness, accidents, or emergency admis-
draws a few broad conclusions about current sions. It is important to note that each of these
trends. Use tends to be concentrated among the indices can present different distributions and
young and, with the exception of nicotine, the demographic correlates in the population. For
more addictive the substance, the more socially example, most of a sample of 100 Canadian
marginalized the user. The gender differential is cocaine users described it as an infrequent, self-
diminishing and while the overall use of illicit limiting behavior (Erickson & Weber, 1994).
drugs has increased in developed countries since This finding was mirrored in a group of Dutch
Introduction 569
Table 1 ICD-10 criteria for substance dependence.
Diagnostic guidelines
A definite diagnosis of dependence should usually be made only if three or more of the
following have been experienced or exhibited at some time during the previous year:
(i) A strong desire or sense of compulsion to take the substance.
(ii) Difficulties in controlling substance-taking behavior in terms of its onset,
termination, or levels of use.
(iii) A physiological withdrawal state . . . when substance use has ceased or been
reduced, as evidenced by: the characteristic withdrawal syndrome for the
substance; or use of the same (or a closely related) substance with the intention of
relieving or avoiding withdrawal symptoms.
(iv) Evidence of tolerance, such that increased doses of the psychoactive substance
are required in order to achieve effects originally produced by lower doses.
(v) Progressive neglect of alternative pleasures or interests because of psychoactive
subtance use, increased amount of time necessary to obtain or take the substance
or to recover from its effects.
(vi) Persisting with substance use despite clear evidence of overtly harmful
consequences, such as harm to the liver through excessive drinking, depressive
mood states consequent to periods of heavy substance use, or drug-related
impairment of cognitive functioning; efforts should be made to determine that
the user was actually, or could be expected to be, aware of the nature and extent
of the harm.
Source: World Health Organization (1992).
nondeviant cocaine users (Cohen, 1994), in have affected the First World War effort. By
which only one in five proceeded to high use, the early 1960s, users of the drug came largely
while sustained problematic use was very much from the middle-aged, male, bohemian classes.
the exception. This distinction between use and When different routes of administration such as
dependence would seem to be manifest when smoking and injecting as well as sniffing
samples are not drawn from biased sources, like became available, the drug began to appeal
the treatment or criminal justice systems. At its to a wider group of users. As noted above, the
peak in the mid 1980s, 25 million Americans widespread use peaked in 1985, but later the
reported having used cocaine, while three advent of crack cocaine meant that the profile
million of these were considered to be dependent of the typical user became more homogeneous;
on the drug (Kleber, 1988). Reinarman, Mur- notably inner-city, socially marginalized young
phy, and Waldorf (1994) conclude that depen- people. This change was mediated by a combi-
dent, harmful use of cocaine is more contingent nation of lower price, more adverse public
on the social circumstances of users and the attitudes and greater dependence-forming po-
conditions under which the drug is taken rather tential. The evolving demographic profile of
than its pharmacological action on human cocaine illustrates the problem of changing
physiology. It is important then to acknowledge fashions in drug use. Babor (1994) notes that
the differing prevalence of use, dependence, and while drugs that have abuse potential seem to
problems across sociodemographic groups. become a public health problem as a function
The demographic profile of a drug can also of the variables outlined above, the decline of
change according to fluctuating availability, drug epidemics is related to many of the same
price, dependence potential of different forms variables.
of the drug, mode of administration, or public
attitude. This has been elegantly illustrated by
Pickering and Stimpson (1994) in their analysis 6.25.1.2 A Longitudinal Perspective
of two centuries of cocaine use in the developed
world. They trace the drug's changing demo- In order to interpret treatment studies it is
graphic profile from the nineteenth century, important to take account of the natural
when it was mainly taken in the USA by middle progression of dependence over time, although
class women. Cocaine lost its nineteenth there have been surprisingly few studies that
century status as a ªtonicº and became a chart a typical drug-using career. This is a
ªsocial problemº when its use by soldiers could psychosocial construct, which takes account of
various environmental influences and develop- 6.25.1.3 Assessment

mental changes that shape drug or alcohol use
and must be understood in terms of the culture Before embarking on a treatment program, a
in which the individual lives. Treatment can be sound assessment is required that will inform
defined as a ªset of facilitative events which may the choice of treatment goal and content.
have the effect of edging an individual into a less Information should be attained on the evolution
destructive long-term career path.º Edwards of drug/alcohol intake, family history, patterns
(1989) has similarly noted that treatment should of current use, degree of dependence, the extent
be conceived of being, at best, a timely nudge or of drug- and alcohol-related problems, reinfor-
whisper in a long-term life course. Most people cement parameters maintaining the behavior,
who successfully work through an addiction and the opportunities within the client's envir-
problem do so on their own without recourse to onment for developing more adaptive re-
treatment. Indeed Prochaska, Di Clemente, and sponses. It is also important to assess the
Norcross (1992) found that so-called self- extent of any co-existing psychopathology.
changers often spontaneously employ strategies There are numerous scales that have been
described in formal therapeutic systems. Klin- developed for the assessment of various aspects
gemann (1994) encapsulated the importance of of drug and alcohol abuse. Normally these
assessing treatment effects within the context of instruments are very general and assess a
the natural history of a drug using career in his composite of variables from a number of
succinct definition of treatment as ªassisted conceptually distinct areas; for example, depen-
spontaneous remission.º dence on the drug, craving, reasons for drug use,
Vaillant (1996) summarizes the long-term attitudes towards self and others, outcome and
relationship between developmental changes efficacy expectations, personal, occupational,
and the onset, maintenance, and possible and social consequences of heavy drug use,
resolution of drug and alcohol abuse. When drug-taking history, and behavior when intoxi-
discussing resolution in particular, he concludes cated. The most widely used screening ques-
his review of longitudinal studies by arguing tionnaire for alcohol abuse is the four-item
that variables such as maturation, treatment, a CAGE (Mayfield, McLeod, & Hall, 1974).
stable premorbid personality, or even social Other common screening instruments include
adjustment may be important in the short term the Michigan Alcohol Screening Test (Selzer,
but play a relatively limited role in eventual 1971), the Alcohol Use Disorders Identification
recovery. Rather, positive long-term outcome Test (Saunders, Aasland, Babor, De La Fuente,
depends more on the eventual severity of & Grant, 1992) and the Drug Abuse Screening
dependence and ªthe individual encountering Questionnaire (Skinner, 1982). Various semi-
the right kind of naturalistic healing experi- structured interviews have also been developed
ence.º There are very few established psycho- to assist in the evaluation of a variety of drug
social predictors that can distinguish between and alcohol abuse variables. Examples include
those alcohol and drug users who achieve stable the Halikas±Crosby drug impairment rating
outcomes and those who do not. However, there scale for cocaine (Halikas & Crosby, 1991) or
seems to be a slowly emerging consensus in the the Addiction Severity Index which assesses the
literature that the key naturalistic factors that severity of problems arising as a result of
contribute to stable outcome include acquisition addiction to one or multiple substances
of an alternative behavior that acts as an (McClellan et al., 1992).
addiction substitute, the discovery of new As noted above these are examples of
sources of hope and self-esteem and the instruments that measure a broad range of
development of new, stable, supportive relation- variables and can be used for general screening
ships. The effects of treatment then must be or assessment purposes. However, they do not
understood against the backdrop of naturally provide the clinician with a pure measure of
occurring influences on the process of recovery. degree of dependence. This is an important
Vaillant (1983) outlines a useful set of ground predictor of eventual outcome and a number of
rules for the ideal evaluation of the natural scales have been developed that are specifically
history of any treatment intervention. These based on the alcohol and drug dependence
include a follow-up period of more than five syndromes. For alcohol, the most commonly
years, outcome assessment at multiple different applied dependence questionnaires are the
times, the inclusion of multiple indicators of Severity of Alcohol Dependence Questionnaire
social functioning, minimal attrition, and con- (SADQ) (Stockwell, Murphy, & Hodgson,
trolling for post-treatment, environmental vari- 1983) and the Short Alcohol Dependence Data
ables. Unfortunately, many treatment outcome (SADD) (Davidson & Raistrick, 1986) in which
studies reported in the literature fall short of this there are 15 items that enquire about most of the
ideal. elements of the alcohol dependence syndrome.
The Stages of Change 571
The severity of opiate dependence questionnaire discourse. The question is not ªcan some
SODQ was designed specifically, as the name alcoholics drink normally?º since the literature
suggests, to assess opiate dependence (Suther- is replete with examples to show that they can
land, Edwards, Taylor, Phillips, & Gossop, (Heather & Robertson, 1985), but rather which
1988). This instrument primarily focuses on the client will benefit most from abstinence and
assessment of withdrawal symptoms and with- who would best be suited to a controlled
drawal relief behavior. As a result it may be drinking goal. More recently the term ªharm
difficult to adapt the SODQ to the measurement reductionº has referred to interventions for
of dependence on drugs that do not produce a drug abusers which involve controlled use
clearly defined withdrawal syndrome. The rather than abstinence. A good example is
severity of dependence scale (SDS) is a five- the resurgence of interest in the methadone
item questionnaire designed to assess the degree maintenance for opiate abusers and the re-
of dependence experienced by users of different ported associated benefits (Ball & Ross, 1991).
types of drugs (Gossop et al., 1995). It was Whatever the treatment goal, a key issue is the
devised to provide a short, easily administered client's commitment to implementing real and
scale and the five items are concerned with the permanent change in his or her pattern of drug
psychological components of the drug depen- or alcohol use. The following section will
dence syndrome. The time frame of inquiry is review some models that assist in our under-
the past year and the items are as follows: standing of the stages in this decision-making
(i) Do you think your use of (named drug) is process.
out of control?
(ii) Does the prospect of missing a fix (or
dose) or not chasing make you anxious or 6.25.2 THE STAGES OF CHANGE
worried?
(iii) Do you worry about your use of (named Psychotherapists have long been interested in
drug)? the process of change. Pentony (1981) noted
(iv) Do you wish you could stop? that most therapeutically induced change in
(v) How difficult do you find it to stop or go cognition, affect, or behavior involves an initial
without (named drug)? destructuring with resistance being a central
The SDS would seem to be a promising research feature, an intermediate stage of conversion,
instrument which can provide an assessment of and a final stage of restructuring. Janis and
the degree of dependence experienced by users Mann (1977) analyzed how all sorts of
of a variety of psychotropic drugs, although as permanent life decisions are made and they
yet it is too early to evaluate its usefulness in note that such change progresses through a
clinical settings. number of stages notably reappraisal, consider-
The assessment process will assist the thera- ing the options, evaluation, action, and con-
pist in tailoring a treatment program to the solidation.
needs of the individual as well as elucidating on Within the addictions literature the idea of
the most appropriate treatment goal. Gossop transitional stages or dispositional states has
(1996) has provided examples of treatment been developed by various authors. Tuchfeld
goals which might include the following: (1976) interviewed a large sample of individuals
(i) Reduction of psychosocial or physical who had recovered from alcohol dependence
problems either directly or indirectly related without recourse to formal treatment regimes,
to the drug problem. and on the basis of these interviews he proposed
(ii) Reduction of risky behavior associated a two-stage model of change. The first is when
with the use of the drug. defensive avoidance becomes untenable and a
(iii) Attainment of controlled or nondepen- commitment to change is made. The second
dent use. stage is one of maintenance of a new behavioral
(iv) Attainment of abstinence from the prob- repertoire, which is characterized by personal
lem drug. vigilance and during which time the individual
(v) Attainment of abstinence from all drugs. develops coping strategies to attenuate the
The issue of controlled use rather than absti- possibility of relapse. Kanfer and Grimm
nence has been debated at length within the (1980) also suggest a number of critical
alcohol field for many years and is perhaps transition points as an individual begins to
symbolic of the difference between the more recognize the need for change, prepares for
traditional disease approach and explanations change, and eventually works towards main-
of alcohol abuse generated from social learning taining change and minimizing the risk of
theory. For this reason the debate was at times relapse.
conducted at a more personal and anecdotal Arguably, the most influential model of
level than is normally the case in scientific change within the addictions field has been
the so-called transtheoretical model of Prochas- are made, after which successful individuals
ka and Di Clemente (1984) and Prochaska et al. enter the maintenance stage when new behaviors
(1992). The stages of change circle is now are strengthened and consolidated. The indivi-
probably as familiar to addiction workers as dual who does not relapse during this stage
Glatts' U-shaped curve. Orford (1992) likened eventually exits the change system to termina-
the development of the transtheoretical model tion, or in other words favorable long-term
to a Kuhnian paradigm shift and suggested that outcome.
it has helped rationalize the diversity of The authors concede that a linear progression
psychological interventions and place them in through the stages could be a simplification and
the context of the evolution of personal change. acknowledge that on occasions a more cyclical
He argued that it allows us to see things from a pattern may be in evidence. People may move
fresh perspective and casts the process of change back from action to contemplation and pre-
in an entirely new mold. The model is contemplation before eventually achieving
summarized in Figure 1. long-term resolution of the problem. A number
The transtheoretical model was originally of questionnaires have been developed to assess
developed after detailed interviews of almost the stage of change for drug abusers, including
1000 successful exsmokers, with success being the eponymous Stages of Change Questionnaire
defined as a period of abstinence of four or more (Prochaska et al., 1992) and the 12-item
years. Essentially during precontemplation in- Readiness to Change scale (Rollnick, Heather,
dividuals do not feel impelled to do anything Gould, & Hall, 1992). Essentially these scales
about their behavior, perhaps as a result of yield a score corresponding to the primary stage
ambivalence, denial, or selective exposure to of change, which is indicated by the person's
information. As they become aware a problem self-perceived intentions and behavior. Heather
exists, they enter the contemplation stage which (1992) argues that the stages of change can now
is characterized by conflict and dissonance. be reliably assessed and have considerable
Preparation is defined as a time when the predictive validity. The key heuristic value of
individual drug user formulates action plans the model is that various categories of inter-
and is serious about his or her intention to alter vention are said to be differentially effective at
behavior. Action is a period when overt changes each stage.
Exit termination
Action
Maintenance
Preparation
Relapse Contemplation
Exit precontemplation Precontemplation
Figure 1 Stages of individual change. Source: adapted from Prochaska, DiClemente, and Norcross (1992).
Psychologically Based Treatment Methods 573
Perhaps as a result of its intuitive appeal to comings, the model of change does provide a
practitioners and researchers alike the model structure to help us match different interven-
escaped any considered criticism in the addictions with the albeit arbitrarily defined stages
tions literature for almost a decade. However, (Davidson, Rollnick, & MacEwan, 1991).
more recently a number of authors have Miller (1983) suggested that motivational
questioned its validity and theoretical cohesive- interviewing is most useful for individuals in
ness. Davidson (1992, 1998) commented that it the contemplation stage, although it can prove
is derivative and noted a number of empirical beneficial for individuals in all stages of change.
and conceptual weaknesses. Sutton (1996) felt Behavioral and cognitive interventions can be
that it was arbitrary to divide a behavioral/ optimally applied in the preparation and
cognitive continuum into five mutually exclu- maintenance stages. In summary, despite the
sive and exhaustive categories. He also re- criticisms, this model remains a useful guide to
analyzed some data on which the model is based assist practitioners in their choice of appro-
and found that individuals did not necessarily priate interventions.
progress through the stages of change in the
sequence predicted by the model. Few subjects
in fact showed a stable progression through 6.25.3 PSYCHOLOGICALLY BASED
three or more stages and, indeed, almost one- TREATMENT METHODS
third of the sample remained in the same stage 6.25.3.1 Motivational Interviewing
throughout the two year time frame. Budd and
Rollnick (1996) applied a broadly similar Motivational interviewing was described by
analysis to scores on the Readiness to Change Stockwell (1992) as the most important and
questionnaire, which revealed a continuum of influential therapeutic development within the
readiness to change. These authors noted that field of addiction over the past decade. In his
while a stage model has greater intuitive appeal, original account of motivational interviewing,
a continuum model provides a better represen- Miller (1983) saw motivational problems as a
tation of the available data. result of the therapist/client dialogue, with the
In a stinging criticism of the transtheoretical behavior of the therapist influencing the
model, Bandura (1997) announced that stage expectations, attributions, and behavior of the
theories are undergoing a dignified burial in client. Denial was said to be a product of the
psychology. He argued that this oversimplified more traditional, confrontational, therapeutic
stage view substituted a categorical approach interaction. During motivational interviewing
for what is essentially a process model of human the individual is encouraged to reach his or her
change. He suggested that people do not recycle own decision about change, while the role of the
through discrete stages but fluctuate in their therapist is simply to facilitate this process
struggle to exercise control over their health through clarification, advice when appropriate,
behavior. The stages of precontemplation and accurate feedback, and empathy. The aim of
contemplation are simply differences in degree therapy is to increase cognitive dissonance until
of intention while the subsequent stages are a critical mass of motivation has been achieved
gradations of the very behavior that the model and the individual is ready to move from
seeks to explain. For example, he noted that the precontemplation to eventual action. At this
action and maintenance stages are simply point commitment to real behavioral change is a
arbitrary subdivisions of the duration of the likely outcome. Motivational interviewers op-
new abstinent behavior rather than differences erationally define motivation as the probability
in kind. In other words, this is simply a that a person will enter into, continue, and
quantitative rather than a qualitative distinc- adhere to a specific change strategy and there is
tion. Less than six months abstinence from a strong emphasis on ambivalence resolution
alcohol or drug use is said to define the action and the decisional balance. Essentially the client
stage, while longer than six months defines the begins to present his or her own argument for
maintenance stage. change rather than being directed by a coercive
While all of these criticisms may be regarded therapist, while it is the therapist's role to set in
as legitimate, the model continues to wield place the optimum conditions for change.
considerable influence in the addictions field Specific motivational interviewing strategies
and it is quite wrong for Bandura to argue that and the treatment rationale have been detailed
the stage models are undergoing a dignified elsewhere (Miller & Rollnick, 1991).
burial. Terms such as contemplation and Motivational interviewing is something of a
maintenance have become entrenched in addic- misnomer in as much as it has little to do with
tions parlance and scarcely an article is written contemporary cognitive theories of motivation.
on treatment in addictions without reference to Rather it seems to be an example of the
the stage of change model. Despite its short- phenomenological approach to change and
adapts the psychology of self-actualization to measure at six months, clients who were
the promotion of personal change among evaluated at baseline as ªnot ready to changeº
alcohol and drug abusers. Miller and Rollnick responded better to motivational interviewing.
(1991) contrast motivational interviewing with This is interpreted as providing support for the
client-centered counseling by arguing, for ex- view that motivational interviewing is most
ample, that empathic reflection is invariably and appropriate for those in the contemplation
noncontingently employed in client-centered stage. Noonan and Moyers (1997) conducted a
counseling but used only selectively in motiva- review of 11 trials that compared motivational
tional interviewing. Furthermore, they say that interviewing with a range of other treatments. It
the good motivational interviewer is not afraid seemed that motivational interviewing was
to proffer advice and will actively attempt to uniquely effective if it succeeded in eliciting
create discomfort and discrepancy rather than positive motivational responses without evok-
passively follow the client. Davidson (1996) ing resistance. It was, however, not particularly
suggests that this analysis is based on something effective in the more severely dependent drin-
of a caricature of the Rogerian position and that kers. Nonetheless the authors concluded that
neo-Rogerian client-centered approaches are motivational interviewing was essential for all
more active and task-focused than was hitherto groups in the assessment interview as it reduced
the case. While the distinction between motiva- attrition rates.
tional interviewing and contemporary client- The enormous popularity of motivational
centered counseling may be little more than interviewing is in contrast to relative paucity of
semantic, this is no bad thing. Motivational positive outcome studies. However, on balance
interviewing is an excellent example of a it would seem that motivational interviewing
therapeutic system, squarely based on psycho- strategies act in some way to resolve ambiva-
logical principles, tailored to individual change lence and promote greater commitment to
in addictive behavior. change.
Rollnick, Heather, and Bell (1992) described
a brief form of motivational interviewing that is
beginning to be used to good effect in primary 6.25.3.2 Behavioral Interventions
care settings. Miller and Baca (1993) found
some evidence of better long-term outcome in a Within the addictions literature the popular-
small group of patients who received a brief ity of behavioral interventions has waxed and
motivational interview over those who experi- waned over the years. During the 1980s, there
enced a more directive, traditional style of was a move away from such treatments, which
interview. Baker, Kochan, Dixon, Heather, and were said to be reductionistic, mechanistic, and
Wodak (1994), however, could demonstrate no deterministic, and they were replaced by much
significant difference in HIV risk-taking beha- more cognitively based multimodal packages of
vior between a brief motivational interview and care. However, there has been a renewed interest
a nonintervention control condition. Kuchipu- in once-popular interventions such as cue-
di, Hobein, Fleckinger, and Iber (1990) found exposure and aversive conditioning which lend
brief motivational interviewing to be unsuccess- themselves to parsimonious explanation in the
ful in reducing future drinking. Saunders, language of conditioning. Cue-exposure is
Wilkinson, and Phillips (1995) present a con- based on the idea that a compulsion (a response
trolled trial of a brief motivational intervention to externally conditioned stimulus cues) will be
with 122 drug abusers attending a methadone reduced if the urge, which Marlatt (1978)
clinic. Subjects were randomly assigned to a defined as intention to carry out the behavior,
motivational condition or a control, educa- is restricted. Cue-exposure can be understood in
tional procedure. After six months, the motiva- terms of both classical and operant condition-
tional subjects showed significantly greater ing. Drug responses, which can include with-
commitment to abstinence, reported more drawal symptoms, antagonistic, compensatory,
positive outcome expectancies and relapsed less or agonostic effects, can become associated with
quickly than the control group. The authors the internal or external environment. Environ-
concluded that motivational interventions can mental cues are the conditioned stimuli which
be a useful adjunct to a methadone program. when presented in the absence of the uncondi-
Heather, Rollnick, Bell, and Richmond (1996) tioned stimulus can produce this variety of
reported a comparison between brief motiva- responses. After classical conditioning, instru-
tional interviewing, skill-based counseling, and mental conditioning will occur if the condi-
a nonintervention control condition in a sample tioned responses become discriminative stimuli.
of heavy drinkers. While there were no Cue-exposure should in theory extinguish the
significant differences between the intervention conditioned response and so alter future
conditions in terms of a quantity/frequency behavior. In practice the client is exposed to
cues which would usually trigger an episode of (1981) demonstrated the superiority of emetic
alcohol or drug use but if responses are therapy or chemical aversion over aversion
prevented or controlled, this weakens the produced to an electric shock and Elkins (1991)
stimulus±response relationship. produced an elegant theoretical rationale for the
Drummond, Cooper, and Glautier (1990) consistent superiority of chemical aversion over
reviewed 20 years of cue-exposure research electrical aversion for alcohol and drug abusers.
within addictions and concluded, rather dis- Nevertheless, there have been surprisingly few
appointingly, that its efficacy must be ques- well-controlled outcome studies that demon-
tioned as there were so few methodologically strate the long-term efficacy of emetic therapy.
sound studies that demonstrate its effectiveness It is possible that most trials to date may not
in producing good quality, long-term change in necessarily have adhered to the conditions that
the behavior of alcohol and drug users. More should promote maximum change. Of central
recently it has been suggested (Davidson, 1996) importance is the temporal continuity between
that this may be due to the possibility that the conditioned and unconditioned response
treatment conditions employed by practitioners and it may be that some of the failures of emetic
have not in fact taken account of the necessary therapy are due to the fact that exposure to
contingencies required to promote maximum alcohol or drugs is introduced after the initial
change in drug-using behavior. He suggests that peak of nausea. Arguably, there is only one
there should be greater emphasis on individual study in the addictions literature to date that is
differences in cue reactivity, only stimuli theoretically and methodological flawless (Can-
relevant to the individual should be included non, Baker, & Wehl, 1981). In this study there
if generalization is to occur in the natural was random assessment of clients to chemical
environment, and individuals should be in- aversion and nonaversion treatment conditions.
structed to focus on the most salient aspects of Optimum contingency intervals were employed
the stimulus. Finally there must be within- and a significant superiority of aversive con-
session habituation. In practice this means that ditioning was demonstrated at one year follow-
there should be individually tailored cues of up. Parloff, London, and Wolf (1986) found
different duration with the termination of each that for some alcohol abusers, aversive proce-
session determined by clear evidence of habi- dures were consistently better than more
tuation of the induced responses. Studies with cognitively based interventions. Hester and
opiate addicts (Powell, Bradley, & Gray, 1993), Miller (1989) have outlined a treatment proto-
which have adhered to a theoretically driven col for covert sensitization (verbal aversion).
treatment design, have produced promising While this offers many practical advances,
results. Drummond and Glautier (1994) com- Elkins (1980) suggested that alcohol misusers
pared cue-exposure with a relaxation control who experience real, rather than suggested,
treatment in a randomized control trial invol- nausea after the taste or smell of alcohol remain
ving a sample of 35 severely dependent alco- abstinent for longer than those who do not.
holics. The cue-exposure clients had a total of However, it is probably fair to conclude, at the
400 minutes of exposure to the sight and smell of time of writing, that the use of aversive
preferred drinks over a 10 day period and procedures for alcohol or drug misusers is
showed significantly greater improvement on a relatively rare.
range of consumption variables at six month Heather and Stallard (1989) suggest that,
follow-up. These recent positive results have generally, contemporary models of relapse
tempered the rather pessimistic earlier conclu- perhaps underestimate the importance of clas-
sions of Drummond et al. Cue-exposure is an sically conditioned craving in the relapse
example of a treatment for which conditioning process. It is likely, therefore, that behavioural
models neatly predict the optimum conditions interventions, particularly cue-exposure, will
for change, without recourse higher order become more important components of treat-
cognitive explanations. ment programs for alcohol and drug abusers
The second example of a treatment based than they have been hitherto.
explicitly on conditioning models is aversive
conditioning, which was graphically described
by Wilson (1991) as a strategy to decrease the 6.25.3.3 Relapse Prevention
appetitive allure of alcohol and drugs. The
general criticism, that aversive procedures are Substance abuse has long been seen as a
inhumane and pejorative, is well known. chronic, relapsing condition. A sound under-
However, in the context of the present discus- standing of relapse management is perhaps the
sion the importance of these interventions are most fundamental issue in a discussion of the
that the conditions of maximum change can be nature of treatment for addictive behavior.
theoretically specified. Cannon and Baker Relapse prevention is a generic term for a
variety of approaches to the treatment of drug cognitive processing. Automatic processes are
and alcohol abuse, primarily aimed at those in characterized by speed, autonomy, effortless-
the maintenance stage of change. Edwards ness, and lack of conscious awareness. Exam-
(1994) points out that it is important to ples are the urges and cravings generated by
remember that relapse prevention ªdoes not drug withdrawal or the reinforcing effects of
imply a single theory of just one intervention drugs. Nonautomatic processes require con-
technique but the deployment of a range of scious effort, the choice of competing strategies,
methods derived from a variety of behavioural the execution of preferred strategies, and the
and cognitive postulatesº (p. 252). modulation of the strategy to take account of
The term relapse has been afforded a number environmental changes. In order to deal with
of meanings by various authors. A lapse is seen what Tiffany calls automatically induced urges
by Gossop (1996) as being part of a transitional and cravings, the individual must mobilize
process which may ultimately lead to favorable nonautomatic cognitive processes which require
long-term outcome, while a relapse is a return to effort, attention, and intention and which can
the original pattern of drug intake. Relapse is lead to overt behavioral and cognitive coping
not necessarily a discrete event that occurs at strategies.
one moment in time, but rather it is the end Most relapse prevention programs therefore
point of the process of returning to former emphasize the importance of a broad range of
patterns of abuse. The process of relapse cognitive and behavioral strategies which will
transcends the actual preferred substance of attenuate the possibility of relapse. Arguably,
abuse. This was demonstrated in a seminal the most influential model developed with the
paper by Hunt, Barnett, and Branch (1971) who addictions field has been Marlatt's taxonomy of
showed similar post-treatment, relapse/survival relapse precipitants.
curves for alcohol, opiate, and nicotine abusers. Marlatt and Gordon (1985) presented relapse
Indeed, relapse prevention models have subse- prevention as a set of principles broadly based
quently been applied to a range of behaviors on social learning theory. In a sample of over
about which an individual has made a commit- 300 individuals who used a variety of drugs, they
ment to behavioral control and has formulated were able to clarify the key relapse precipitants
a set of rules to govern this control. It was not into two broad categories. The first includes
until the 1970s that addiction researchers began intrapersonal precipitants such as negative and
systematically to examine the nature of the indeed positive physical and emotional states.
processes involved in relapse. Since then a For over one-third of alcohol and nicotine
number of leading models have emerged to abusers and about one-fifth of heroine abusers
guide our thinking and these have been reviewed the main relapse precipitant was a negative
by Connors, Maisto, and Donovan (1996). emotional state. The second category is inter-
Gloria Litman and her colleagues (e.g., personal precipitants of relapse including re-
Litman, Eiser, Rawson, & Oppenheim, 1977, lationship conflict and indirect or direct social
1979) saw relapse as a person±situation inter- pressure.
action. Of primary importance was the high-risk As part of a relapse prevention program,
situation and the effectiveness and appropriate- Marlatt and his colleagues suggest that indivi-
ness of the individual's coping skills for dealing duals are taught to recognize the possibility of
with it. Relapse was more likely in individuals relapse. Essentially the client constructs a
who had few coping resources and who personal behavioral analysis and receives train-
encountered a relatively large number of risk ing in specific coping strategies. These can
situations. Sanchez-Craig (1987) placed more include broad-based skills training (behavioral
emphasis on the individual's perception and rehearsal, assertiveness training), cognitive
appraisal of the risk situation rather than the reframing (coping imaginary, reframing reac-
situation itself. Relapse has also been system- tions to lapse), and lifestyle interventions
atically approached from what has been called a (relaxation and exercise enhancement). All of
psychobiological perspective. Central to these these have been found to contribute to the
models is the idea that relapse is precipitated by effectiveness of a relapse prevention program.
craving, which results in loss of control. Craving Clients are taught to recognize early warning
can be seen as a cognitive interpretation of the signals and made aware of apparently irrelevant
feelings of arousal associated with drug-related decisions that can increase the possibility of
stimuli. Solomon's (1980) opponent process relapse. Emphasis is placed on the modification
model defines craving as the interplay between of cognitive distortions and the challenging of
positive and negative emotional states, induced faulty beliefs or dysfunctional assumptions. For
by the substance. Tiffany (1990) formulated a example, the abstinence violation effect is a
model of drug use and relapse which highlighted distorted redefinition of lapse as relapse, so
the importance of automatic and nonautomatic undermining the effectiveness of future coping
behaviour. The Marlatt and Gordon relapse Situational Confidence Questionnaire measures
prevention program is therefore a combination perceived ability to cope effectively with a
of skills training, self-management, and cogni- variety of drug-related risk situations. More
tive interventions and the client is encouraged to recently Moser and Annis (1995) have empha-
practice these strategies using rehearsal, role- sized the role of coping strategies in their
play, and homework tasks. cognitive behavioral model of relapse. They
Carroll (1996) carried out a detailed review of demonstrate that the survival of a relapse is
24 controlled trials that have evaluated the strongly related to the number and type of
effectiveness of relapse prevention across a coping strategies employed. Avoidance strate-
range of addictive behaviors including nicotine, gies are less effective in preventing relapse than
alcohol, marijuana, opioid, and cocaine abuse. active strategies, such as carrying out alternative
In the review, she included only those trials that activities, seeking support from others, positive
specifically employed the relapse prevention self-talk, and cognitive problem-solving.
model of Marlatt and Gordon (1985) and that The relapse prevention models described
were, in her opinion, methodologically sound. above have been developed specifically within
The outcome variables were primarily post- the addictions field, but their use has extended
treatment patterns of substance use, rather than to a range of other clinical contexts, for
behavioral and cognitive indicators such as example, anxiety management, eating disor-
coping skills, self-efficacy enhancement, or ders, and impulse control. However, there is
social adjustment. The review concluded that also a series of models primarily used to inform
there was some evidence of effectiveness of this research on health behavior decision making
type of relapse prevention approach across a that emphasize the importance of cognitive
range of substances, particularly smoking processes as crucial determinants, not only in
cessation, when compared with no treatment the abstention from risky behavior, but also the
controls. However, its superiority over other adoption of health beneficial behavior. These
active treatments and discussion control con- models have recently been employed within the
ditions was less consistent. The specific benefits addictions field.
over other treatments were in reducing the One of the first and most influential was the
severity of relapses if they occurred and the Health Belief Model (Becker, 1974) which
approach seemed to be of most value for clients expressed the likelihood of positive health
with more severe dependence or higher levels of decision-making in terms of a cost±benefit
psychopathology. The Relapse, Replication analysis. This was superseded by the theory of
and Extension Project (RREP) was a major reasoned action (Ajzen & Fishbein, 1980) and
multicenter trial established to investigate the then came the theory of planned behavior
validity and reliability of Marlatt's taxonomy of (Ajzen, 1988). This latter model specified a
relapse precipitants (Lowman, Allen, & Stout, number of variables that predict intention and
1996). Essentially the study confirmed the behavior, namely control beliefs, subjective
predictive validity of a modified version of norms, and attitudes (a form of outcome
Marlatt's taxonomy, although it did raise some expectations). These health belief models have
questions about differences between proximal been refined and developed by Ralph Schwarzer
variables associated with time-limited relapse in his Health Action Process Approach
and variables that predict outcome in the longer (HAPA). This idea is now widely applied to
term. the understanding of the fluctuating relapse/
The relapse prevention model of Annis and survival process of addictive behavior. Schwar-
Davis (1989) draws more explicitly on self- zer (1992) comments that traditional relapse
efficacy theory. The emphasis of this approach prevention approaches, such as that of Marlatt
is on performance-based methods, notably the and Gordon (1985), have focused on the
exposure to increasingly high-risk situations maintenance stage and have not promoted
with continuing self-monitoring of efficacy understanding of change strategies in the
expectations. In guiding the client through risk motivational and action phases of change.
situations, Bandura's (1985) four factors that Essentially, within the motivation phase the
engender strong efficacy expectations are taken individual forms an intention to adopt precau-
into account. First, the situation is challenging; tionary measures for changing risk behavior in
second, to succeed in mastering the situation a favor of other behaviors. The action phase is an
moderate degree of effort is needed; third, the attempt to explain the relationship between
client is responsible and external help is kept to a intention and subsequent behavior, with em-
minimum; and fourth, the success is described as phasis being placed on action control and action
part of a pattern of improved performance. The plans. Estimates of the relative proportion of
Inventory of Drink Situations helps identify the outcome variance explained by predictors of
client's areas of high risk of relapse and the intention and behavior have been gleaned from
a variety of sources. For example, outcome admission of character deficits, restitution,

expectations and the perception of subjective pledge taking, and bible reading. Bill W. used
norms contributed to about half of the variance this as a metaphor for the organizing principles
in intention to stop smoking, but rather of AA. At an AA meeting open sharing is
disappointingly stated intention to stop smok- encouraged and members admit their power-
ing accounts for only about 20±25% of the lessness over alcohol. The AA belief system is
variance in actual observed long-term smoking articulated in the 12 steps, which include the
abstention. However, when beliefs about requirement of a searching personal inventory,
personal efficacy are added to the model, its commitment to a greater power, making
explanatory power increases substantially. amends to other people, and carrying the
Schwarzer concludes that self-efficacy expecta- message to other alcoholics. Essentially, the
tion, or the belief that addictive behavior can be AA model of addiction is one of an illness which
changed by mobilizing personal resources, is can only be arrested by complete and life-long
the most powerful predictor of intention and abstinence from alcohol; an illness that is said to
subsequent behavioral control. This view was be arrested but never cured. All attenders, no
supported by Kok, De Vries, Muddle, and matter how long they have been alcohol-free,
Strecher (1990), who demonstrated that effi- remain designated as recovering alcoholics. An
cacy expectations alone could account for over analysis of AA-mediated processes of recovery
two-thirds of the outcome variance of intention suggests that motivation can be bolstered by the
to stop and subsequent smoking abstinence. use of proximal goals (a day at a time) for
The total predictive effect of self-efficacy on the everyone from the first attender to the 20 year
maintenance of health behavior exceeds the abstainer. Emphasis is placed on role modeling,
effect of any combination of other cognitive with constant recourse to a pay-off matrix in
variables. Bandura (1997) agrees, and con- which the profit of staying sober is compared to
cludes his review of models of health behavior the loss of being drunk. AA also offers, in the
by noting that outcome expectations have best relapse management tradition, alternative
variable effects, normative influences have little activity and new social networks. Much AA
effect but efficacy expectations are constantly folk wisdom, such as not getting angry, tired, or
predictive. bored; monitoring thinking tricks, and self-
In summary, the work of Annis, Schwarzer, justifying statements, is the stuff of social
Bandura, and others indicates that self-efficacy learning theory. This prompted Edwards
is emerging as the most powerful predictor of (1996) to compare an AA meeting to a cognitive
relapse/survival across a variety of addictive behavioral workshop. In a small sample of AA
behaviours. Allsop, Saunders, Philips, and attenders, Edwards et al. (1987) found that the
Cann (1997) suggest that training in coping most valued AA activity was hearing other
skills is not enough, people must use the skills at people's stories and the least valued was the
the right time for them to be effective. The quasi-spiritual element.
practice of coping skills improves self-efficacy Tonigan, Ashcroft, and Miller (1995) exam-
so that the skills can be deployed in real-life risk ined three AA groups in terms of perceived
situations. Furthermore, in recent years there social dynamics and the relative emphasis on the
has been much cross-fertilization of ideas 12 steps. The groups significantly differed in
between relapse prevention models developed terms of cohesiveness, independence, and
primarily for substance abusers and more expressed aggression and it was found that 12
general models of health decision-making step discussion was lowest in the groups with the
behavior. highest aggressiveness. In the light of these
results it was suggested that AA need not be
regarded as a homogeneous entity and a clear
6.25.3.4 Psychosocial Interventions understanding of the variation among AA
groups needs to be gained before we can make
The prototypical, community self-group is definitive statements about its effectiveness.
Alcoholics Anonymous (AA) which was Davies (1992), in his attributional analysis of
founded in 1935 by a serendipitous meeting what he called the ªmyth of addition,º argued
between two American alcoholics, Bill W and that step one, which is an admission of power-
Dr. Bob. Advice to attend AA remains part of lessness over alcohol, can absolve the individual
many contemporary multimodal treatment of personal responsibility for his drinking. It
packages for alcohol abuse. The principles of minimizes the importance of a functional
change espoused by AA are based on the explanation of drinking behavior and Davies
Oxford group, a religious organization in the would say that it does not bode well for dealing
evangelical Protestant tradition (Bill W., 1957), with relapses should they occur. Ogbourne
which emphasized self-examination, the public (1993) observed that we know little about the
Issues in Treatment 579
real long-term effectiveness of AA because as a Smart (1976) reviewed outcome studies on

matter of principle the organization keeps no community graduates and suggested that when
records of the success and failures of its recovery is defined solely in terms of patterns of
members. Furthermore as noted above, AA is drug use, outcome is fairly good. However when
less homogeneous than many people think. other outcome indices are employed, for
There is no doubt that AA, with its rigid example future employment, the results are less
explanations and emphasis on abstinence, does encouraging. Thorley (1981) reviewed a number
not suit most alcohol abusers and so attrition of UK studies and concluded that therapeutic
rate is high (Miller & McCrady, 1993). Edwards communities for drug abusers can greatly
(1996) cautions ªthe evidence that AA works is benefit some individuals but can actively harm
suggestive and rests on the evidence of its others. It is also difficult to specify the optimum
popularity and seeming ability to meet need, duration of care within such communities. For
rather than being a matter of proven factº example, McCusker et al. (1995) compared a six
(p. 235). Nonetheless, for some people it is the month with a 12 month therapeutic community
belief that they are personally powerless over program for a mixed group of drug abusers and
alcohol which can inspire faith and promote found no difference on a whole range of
change (Keene & Raynor, 1993), and it is psychosocial variables and pattern of drug
indisputable that the profound and interna- use at six month follow-up. While therapeutic
tional influence of AA belies its humble communities may arguably be an effective
beginnings. Narcotics Anonymous (NA) was rehabilitation system, they are relatively few
established in 1953. Christo and Franey (1995), in number and normally have quite strict
in a six month follow-up of over 100 graduates entrance criteria, thus rendering them genuinely
from a residential program, found that NA unavailable to all but a small minority of
attendance was inversely related to continued alcohol and drug abusers.
drug use and that spiritual beliefs or beliefs in One final addendum to the AA story is the
the disease concept were not prerequisites for remarkable growth of the 12-step model within
NA attendance. the USA for the ªtreatmentº of a whole range of
The 12-step approach has been the basis of so-called appetitive disorders. Almost any
many community residential groups for alcohol potential problem from shopping to sex has a
and drug abusers. The 12 steps have been 12-step residential program for individuals
intermeshed with Maxwell Jones's (1956) pio- prone to excess. This raises fundamental
neering models of therapeutic communities to questions about choice, compulsion, and voli-
produce concept houses, such as the original tion in our understanding of human behavior.
Phoenix House in New York, which provided Stanton Peele (1989) in his best-selling book,
long-term residential programs for addicts. Diseasing of America, argues that there is now
Most of the emergent therapeutic communities more ªtreatmentº for everything and this
in the North America and the UK can trace inevitably undermines an individual's personal
their roots back to the Phoenix House program. perception of control over his or her behavioral
Contemporary Minnesota Model programs outcomes. Self-efficacy, so important in the
vary from group to group, but they are generally treatment of any addictive behavior, is being
based on the first half of the 12 steps and include diluted by what Peele calls the ªtherapeutic
group work, lectures, and individual assign- colonisation of our lives.º One can only
ments, all of which can be preceded by speculate how Bill W. and Dr. Bob would have
detoxification. When appropriate there is reacted to the widespread use, perhaps abuse, of
family involvement, which will typically draw their simple approach. Maybe it has gone one
on the principles of Al Anon. DeLeon (1995) step too far.
noted that not all residential drug abuse
treatment programs are therapeutic commu-
nities and not all programs calling themselves 6.25.4 ISSUES IN TREATMENT
therapeutic communities employ the same
psychosocial models of treatment. However, There are two key issues relating to the
the core themes of the drug and alcohol provision of treatment within addictions that
therapeutic communities are those identified have been the subject of much debate in recent
over 30 years ago by Rapoport (1960), namely years. The first relates to treatment intensity and
democratization, communalism, and reality the emergence of a plethora of so-called brief
confrontation. More recently, Norton (1996) interventions for substance abusers. The second
has usefully reviewed the change process is the long-held assumption by most workers in
inherent in therapeutic communities and noted the field that treatment should be tailored to the
that it is difficult to specify the components of needs of the individual. In other words, which
programs that best predict positive outcome. intervention for which client by which therapist
is the most efficacious? Most of the ideas on Heather also highlights the possibility of type
parameters of treatment have been developed in two error, in that this family of studies is
studies of alcohol abuse and it is this literature essentially proving the null hypothesis. It is an
that will primarily be covered in the following inferential error to conclude on the basis of a
review. lack of significant difference between intensive
and brief intervention that they are equally
6.25.4.1 Treatment Intensity effective. Even with a large sample and sufficient
statistical power, which is not the case in most of
There have been over a dozen randomized the trials, one can only conclude that there is no
controlled trials comparing the dose±response evidence of difference in effectiveness. Heather
relationship in populations seeking psychologi- concludes his methodological critique by sug-
cal treatment for alcohol problems. In this gesting that it is at best premature, and at worst
context brief intervention is defined as one to cavalier, to argue that highly dependent,
three sessions of specialist treatment. A distinc- treatment-seeking alcohol abusers gain as much
tion should be drawn between minimal inter- from brief interventions as they would from
vention or advice in a primary care setting and more extended intervention.
brief intervention within a specialist context. There is, however, some merit in investigating
The seminal study on brief intervention was the so-called active ingredients of brief inter-
reported by Edwards et al. (1977), who followed ventions which seem to be, at least, relatively
up a sample of 100 male alcoholics, all of whom successful. Miller and Sanchez (1993) reviewed
had a three hour initial assessment. Half of the the protocols of a large number of brief
men then received a single session of direct interventions and isolated some critical condi-
advice and the other half were offered the tions or key elements that facilitate change in
standard intensive treatment package of the addictive behavior. These can be summarized by
time which included medical interventions, the acronym FRAMES, representing feedback,
introduction to AA, and hospital admission responsibility, advice, menu, empathy, and self-
when appropriate. This study is well documen- efficacy. Essentially their findings would suggest
ted elsewhere but the key conclusion, which has that for brief interventions to be successful the
influenced thinking on delivery of care to client should be given realistic and accurate
alcoholics, is that even after a 10 year follow- feedback about any drug-related impairment,
up there was no significant difference between emphasis should be placed on personal control
the groups on a host of outcome measures. and efficacy with corresponding attention to
Subsequent, similar trials have more or less feelings of helplessness and powerlessness, good
confirmed this finding. Bien, Miller, and advice should be proffered, and the client
Torigan (1993) reviewed this body of work should be given a choice of preferred change
and concluded that there are remarkably few options. Finally, and arguably most important,
differences between brief and extended inter- therapeutic styles should be empathic rather
ventions for treatment-seeking alcoholics. Well- than confrontational. While acknowledging
planned, brief interventions produced similar Heather's caveats, the brief intervention litera-
outcomes when compared with more extended ture does offer hope that for some drug and
psychosocial interventions, with only two alcohol abusers, treatments that are structured
studies reporting a slight advantage for the along these lines could offer potential long-term
latter. benefits.
The dose±response literature should, how-
ever, be interpreted with some caution. These 6.25.4.2 Treatment Matching
studies are notoriously difficult to design and
most of the controlled trails comparing brief Almost invariably, any review of the treat-
with extended treatments have been subject to ment of addictive behavior concludes with a
some criticism. Indeed Orford (1980) would comment that intervention should be matched
concede that the Edwards' trial was by no means to the needs of the client. For example, Gossop
methodologically flawless. Heather (1995) has (1996) notes that ªfor all types of drug problems
recently produced a useful evaluation of the that require treatment the intervention offered
literature. He argues that brief interventions should be tailored to the needs and circum-
tend to be seen as a homogeneous category and stances of the individualº (p. 159). Raistrick and
researchers, as well as practitioners, have paid Davidson (1985) say that ªtherapy should be
insignificant regard to heterogeneity of this type tailored to the individual. What is useful for one
of intervention. Furthermore, there are impor- person may be singularly inappropriate for
tant differences between treatment-seeking anotherº (p. 154). Miller and Herster (1986) say
populations as distinct from those that are that ªclients should be matched to optimal
selected as a result of opportunistic screenings. interventionsº (p. 27), and so it goes on.
Conclusion 581
However, these apparently obvious and interventions were equally effective. With the
laudable matching sentiments have recently exception of psychiatric morbidity, matching
been the subject of some scrutiny in the alcohol client characteristics with treatment did not
literature. Edwards and Taylor (1994) report a enhance outcome. This one ªmatchº seemed to
study that explored the interaction among indicate that outpatients with greater psychia-
treatment intensity, client characteristics, and tric morbidity responded better to CB than
12 month outcome. There were no interactive TSF. However, the overall conclusion of the
effects and the authors conclude that the study was that the general lack of robust
matching hypothesis was not confirmed. These matching effects means that practitioners need
data suggest that individual characteristics such not take these individual characteristics into
as degree of dependence on alcohol or socio- account when triaging clients to one or other of
economic class, rather than client/treatment the three treatment interventions, despite their
matching, may best predict outcome. Edwards different philosophies. This is a counterintuitive
and Taylor draw the tentative conclusion that and radical finding which will undoubtedly
relatively weak matching differentials are resonate in the alcohol treatment field for
masked by developmental or environmental decades to come. Despite the methodological
influences on the process of recovery. rigor, it may be argued that the 12-week
Of particular interest in this regard is Project protocol for CB and TSF and the four-session
MATCH which Heather (1996) describes as the MET intervention do not reflect the range or
largest treatment trial ever mounted in the richness of available interventions, particularly
alcohol field. It was funded by the National those based on social learning theory. The
Institute on Alcohol Abuse and Alcoholism and length of follow-up was only 15 months in this
involved over 1600 clients tracked over a 15 first Project MATCH publication and it could
month period. Meticulous attention was paid to be that matching effects become manifest much
all aspects of the trial design which essentially later. Furthermore, it is unclear about the
tested the relative merits of a variety of client/ validity of cross-cultural application of these
treatment combinations. Clients were randomly results. For example in the UK, Woodhouse
assigned to one of the three treatment mod- and Davidson (1996) matched broadly similar
alities namely 12-step facilitation (TSF), cog- interventions with motivational stage and while
nitive behavioral coping skills (CB), and what there was no significant difference in a quantity/
was called motivational enhancement therapy frequency measure at one year, they found a
(MET). TSF was based on the methods of small but significant matching effect at two
Alcoholics Anonymous, but as it was only years. Essentially contemplators responded
conducted for 12 sessions, did not include relatively better to motivational interviewing,
regular and life-long AA attendance as part of while those in the action stage were best suited
the treatment condition. CB was limited to 12 to relapse prevention strategies. While this latter
sessions of coping skills training, and MET was finding may not be clinically significant, it may
a four session program based on the principles add some weight to the possible criticisms of the
of brief motivational counseling as outlined Project MATCH trial regarding cross-cultural
above. A variety of client characteristics were generalizability of the findings and the relatively
assessed, including motivational status, self- short follow-up period.
efficacy, degree of alcohol dependence, extent of
social support, the number of alcohol-related
problems, psychiatric morbidity, and cognitive 6.25.5 CONCLUSION
impairment. Obviously the interactions between
client characteristics and intervention were as A number of conclusions can be drawn from
important as any potential main effect between this review of cognitive and behavioral ap-
treatment conditions. The primary objective of proaches to the treatment of addictive behavior.
the study was to determine which of various Most of the interventions described in the
subgroups of alcohol-dependent clients would chapter have been offered to users of a range
differentially respond to the three broad inter- of substances. There has been a tendency to
ventions. Additionally, the interaction of treat- assume, not unreasonably, that the important
ment location (inpatient vs. outpatient) with component of any intervention is the cognitive
client characteristics and mode of intervention and behavioral changes that accrue irrespective
was examined. of the preferred drug of abuse. While this is
In summary, the results indicated significant intuitively appealing, it would seem that it is not
and sustained improvement on a range of always the full story. For example, at the risk of
outcome variables across the three main treat- oversimplification, relapse prevention proce-
ment conditions (Project MATCH, Research dures are clearly useful for smokers, moderately
Group, 1997). In other words all three types of effective for alcohol abusers, and have some
variable effect, according to the available cost considerations rather than what is best for
literature, as a treatment for cocaine abuse. each individual. Room (1980) did well to remind
There has, as yet, been no demonstrable sig- us that the basic justification for providing
nificant improvement against a control condi- treatment should be primarily for reasons of
tion for the relapse prevention treatment of humanity rather than cost±benefit analysis.
marijuana use (Stephens, Roffman, & Simpson,
1994). Klingemann (1994) has speculated about
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6.26
Cognitive Approach to
Understanding and Treating
Pathological Gambling
ROBERT LADOUCEUR
UniversiteÂ Laval, QueÂbec, PQ, Canada
and
MICHAEL WALKER
University of Sydney, NSW, Australia

6.26.2 MOTIVATION TO GAMBLE 588
6.26.3 DEPARTURES FROM NORMATIVE DECISION MAKING IN GAMES OF SKILL AND GAMES
OF CHANCE 590
6.26.4 DEVELOPMENT OF GAMBLING PROBLEMS 590
6.26.5 DEFINITION AND ASSESSMENT OF PATHOLOGICAL GAMBLING 592
6.26.6 PREVALENCE OF PATHOLOGICAL GAMBLING 592
6.26.7 PSYCHOLOGICAL TREATMENT OF PATHOLOGICAL GAMBLERS 593
6.26.7.1 Changing Erroneous Beliefs Concerning Randomness 594
6.26.7.2 Problem Solving Training 596
6.26.7.3 Social Skills Training 596
6.26.7.4 Relapse Prevention 596
6.26.8 EFFICACY OF A COGNITIVE/BEHAVIORAL TREATMENT FOR PATHOLOGICAL GAMBLERS 597
6.26.8.1 Case History 597
6.26.8.1.1 Identification and correction of faulty cognitions toward gambling 598
6.26.8.1.2 Problem solving and social skills training 598
6.26.8.1.3 Relapse prevention 598
6.26.9 EVALUATION OF A COGNITIVE TREATMENT FOR PATHOLOGICAL GAMBLING 598
6.26.10 COMMON DIFFICULTIES IN THE TREATMENT OF PATHOLOGICAL GAMBLERS 599
6.26.11 CONCLUDING REMARKS 599
587
588 Cognitive Approach to Understanding and Treating Pathological Gambling
6.26.1 INTRODUCTION or future event; gaming refers to playing for

money in a game of chance; and lotteries refers
The twentieth century has been described as to the distribution of prizes by drawing lots.
the ªhinge of history.º This description follows Although these three kinds of gambling have
from the wide range of indications of social, much in common at the structural level, they are
economic, and environmental measures showing completely different sociologically.
catastrophic change. One of these indications is Claiming that people want to gamble does not
the general public's level of involvement in advance our knowledge of gambling to any great
gambling activities. Rowntree (1941) compared extent, but immediately raises the question as to
the standard of living of the residents of New why people want to gamble. Understanding the
York City in 1899 and 1936. In his analysis of motivation to gamble would appear to be central
leisure in everyday life, he reached the conclusion to understanding why people may gamble
that gambling had grown enormously over that excessively, and can be expected to have an
period of time. It is well-documented that, since important bearing on how gambling-related
1936, gambling has continued its rapid growth suffering may be alleviated, diminished, or
not only in the USA, but throughout the world avoided.
(Frey & Eadington, 1984; McMillen, 1996). In This chapter argues that the motivation to
explaining the upsurge in gambling, the British gamble is seen as the acquisition of wealth and
Royal Commission on Lotteries and Betting that the real problems in explaining gambling
(1933, p. 60) stated that, ªOne of the main causes, concern why it is that gamblers believe that
perhaps the most potent in the growth of money can be won. Because the belief of gambers
gambling, has been the increased facilities for that money can be won is erroneous, it follows
organized gambling.º Similar views have re- that therapeutic methods which change the false
peatedly been expressed by contemporary ob- beliefs of the gambler are more likely to be
servers of gambling (Connor, 1983; Cornish, effective. This proposition is examined in detail.
1978; Dickerson, 1984: Orford, 1985). However,
the claim that the rapid growth in gambling is 6.26.2 MOTIVATION TO GAMBLE
attributable to the legalization and the accessi-
bility of gambling outlets may be considered Gambling explicitly involves the attempt to
false, or at least incomplete. Betting shops, win money by staking money on an uncertain
gambling machines, lotteries, and casinos would event. As a starting point in the attempt to
be useless if ordinary people did not want to understand the motivation to gamble, the
gamble. Even in societies where gambling has acquisition of wealth can be assumed to be
been prohibited, gambling games have never- the prime motivation. The problem with this
theless flourished (Dixon, 1996). assumption is that all legalized forms of
Prior to discussing why people want to gambling are constructed so that the expected
gamble, it is important to specify what we are return is less than the sum wagered. For
referring to when using the word ªgambling.º example, a roulette wheel with one zero takes
Research on gambling does not incorporate all in, on average, 1/37 of the money staked.
risk-taking behavior, but only a limited range of Totalizators typically take in approximately
such behavior. The essential nature of gambling 20% of the money wagered in racing (Ladou-
is that money (or its equivalent) is risked on the ceur, Giroux, & Jacques, 1998) and lotteries
uncertain outcome of an event, subject to certain typically take in approximately 40% of the
conditions: (i) gambling occurs in a group revenue from ticket sales. These percentages
context whereby after costs, taxes, and profits, vary from place to place and according to the
the money wagered by the losers is redistributed structure of the distribution of prizes or returns,
to the winners; (ii) the redistribution of money is but in all cases the expected return on money
independent of any other commercial enterprise invested constitutes a loss for the gambler. Thus,
related to the gambling event. This definition if the acquisition of wealth is the individual's
excludes insurance such as life or property goal, rational economic considerations would
insurance. This definition of gambling is similar lead people to avoid gambling. This is the
to those put forth elsewhere (Perkins, 1950). principal paradox of gambling: people, in
It should be noted that all definitions of attempting to gain wealth, engage in an activity
gambling appear to differ with respect to what is which is expected to decrease wealth.
included or excluded. This problem can be The gambling paradox can be resolved in two
overcome if the activities to be included are different ways: (i) accepting that the acquisition
listed explicitly. In this context, three broad of wealth is the motivation, but the gambler
categories of gambling have been identified: misjudges the chance of winning; or (ii) rejecting
betting, gaming, and lotteries. Betting refers to the acquisition of wealth as the sole or central
staking money on the outcome of an uncertain motivation involved.
Motivation to Gamble 589
The majority of theories of gambling behavior state that they gamble in order to win money.
reject the acquisition of wealth as being the The important question is whether or not the
fundamental motivation for gambling behavior. opinions of gamblers as to why they gamble
However, cognitive theories of gambling assume should be accepted indiscriminately. A certain
that the acquisition of wealth is the primary amount of validation of the data derived from
motivation involved, and that people do not other sources is a minimum requirement.
behave as they normally would with respect to Consider, for example, the claim that gambling
that motivation. According to cognitive the- is exciting and that the rewarding value of the
ories, gamblers hope to win money or believe excitement is the main reason why most people
that they will win money. Why people should gamble. If this claim is true, then several
hope to win or expect to win in the face of the implications follow:
adverse odds involved is the central concern of (i) Behavioural observation should support
such theories. the self-report data. Gamblers should appear to
By contrast, other theories of gambling be excited when gambling. Excitement should
assume that winning money is not the principal be apparent on faces (laughing and smiling), in
motivation for gambling. One cluster of such exclamations of delight, and in the general
theories assumes that it is the amusement and bodily tension and alertness.
excitement (the change in arousal level) that (ii) Physiological measures should support
motivates gambling behavior. In the behaviorist the self-report data. Gamblers should exhibit
form of these theories, the changes in arousal raised levels of heart rate, blood pressure, and
reinforce the gambling behavior (Dickerson & palmar sweating. Neurophysiological measures
Adcock; 1987; McConaghy, 1980), whereas in should also suggest general arousal.
more purposive theories, gambling has the (iii) Indications of excitement should not be
function of changing mood (Brown, 1996) as highly correlated with winning. If excitement
when the excitement of gambling overcomes always accompanies winning and no other
boredom. In some cognitive behavioral explan- events within the gambling cycle, then it is
ations, arousal retains a dominant role but must not possible to know whether it is the winning
be coupled with appropriate cognitions (Sharpe or the excitement which maintains the behavior.
& Tarrier, 1993). A second cluster of theories (iv) If an explanation of gambling in terms of
places more emphasis on personality dimensions the reward value of excitement is to be general-
and, more specifically, on impulsiveness (Blas- ized, then the indicators of excitement should be
zczynski & McConaghy, 1994). It is assumed present for all forms of gambling.
that risk-oriented individuals are attracted to Surprisingly, there is very little evidence sup-
gambling and that problems arising from porting any of these specific implications. Here,
excessive gambling can be attributed to impul- we briefly review the evidence.
siveness. Yet other explanations see the gam- Excitement is most easily observed in certain
bling as largely irrelevant: gambling is simply forms of betting and gaming, and among the
one possible means of escaping or avoiding winners of lottery prizes. Thus, the noise of
stresses and associated anxiety elsewhere in the the crowd at a race track reaches a crescendo as
individual's life. All such theories assume that the leading horses reach the winning post. Simil-
the principal reward for gambling is something arly, certain casino games, such as craps and
other than money. Some support for this view two-up, have been described as suitable for the
comes from the gambling industry which regards extrovert in view of the manifest excitement of
gambling as a leisure activity in which the money the players (Allcock & Dickerson, 1986). How-
expended by the gambler buys the gambling ever, such observable excitement is not sufficient
product. The product is understood to be the evidence. Observable excitement is less in off-
amusement and excitement of the gambling course betting shops and may be largely absent
venture. Thus, gambling is viewed as a desirable among home gamblers with phone accounts.
activity in itself, similar to eating in a restaurant Furthermore, certain casino games, such as
or playing a round of golf. The money spent by blackjack and pai gow, are traditionally played
the gambler pays for the enjoyment received. with a minimum display of emotion. In poker,
It might seem that these alternative explan- the ideal involves an absence of genuine emo-
ations for gambling have a certain face validity. tion. Thus, there are many examples of gambling
If, after all, it is unreasonable to expect to win situations in which no excitement is expressed.
money by gambling, then surely some other Different measures of physiological arousal
factor must be involved. When gamblers are may be used in gambling research. Increases in
questioned about why they gamble, the majority heart rate have been reported for blackjack
of answers concern amusement, excitement, and (Anderson & Brown, 1984) and changes in skin
relief of boredom. By contrast, only a minority conductivity for slot machines (Sharpe, Tarrier,
of individuals involved in betting and gaming Schotte, & Spence, 1995) when players begin a
session. It is likely that arousal increases at the figure in their play (Griffin, 1987; Wagenaar,
beginning of all gambling sessions. However, 1988; Walker, Sturevska, & Turpie, 1995).
excitement prior to gambling cannot be a Analysis of the errors in play shows that in
reward for gambling. More importantly, arou- general the players adopt strategies which are too
sal must be demonstrated to correlate with conservative. Players tend to sit when they
events within the gambling session. In a detailed should hit, avoid splitting pairs when it is
study of slot machine gambling through time, desirable, and take out insurance when it is
Dickerson (1993) did not find any correlation unnecessary (Wagenaar, 1988; Walker, 1995).
between player arousal and the events within a Interestingly, the departures from normative
session. Although variations in arousal have play in poker tend towards risk rather than
been demonstrated for certain gambling-related avoidance of risk. For example, players in five
events, the failure by Dickerson to show that card stud tend to stay in the pot with a small pair
arousal is correlated with machine events in slot when they should fold (Yardley, 1957). In draw
machines is an important obstacle for an poker, players will draw to hands with very small
excitement-based explanation of gambling. probabilities of success, and professional poker
Furthermore, the low numbers of positive players prefer games in which the action is loose,
reports of arousal in relation to the wide range that is, risky (Hayano, 1977; Yardley, 1959).
of gambling, casts doubt on the ability of There are many systems for betting on horse
excitement-based theories to have wide explan- races and, as the variations between the systems
atory power. However, as discussed in detail are great (Allcock, 1987; Beyer, 1993; Drapkin
later, arousal has been found to be associated & Forsyth, 1987; Scott, 1982) and no more than
with erroneous perceptions that create an one can be accurate, it follows that the majority
illusion of control and result in the over- of systems yield less than optimal decisions.
estimation of the probabilities of winning. More generally, betting patterns have been
Interestingly, arousal decreased when erroneous observed to vary across a race meeting with
perceptions were corrected (Giroux, Ladou- betting on the last race at the meeting being
ceur, & Jacques, 1998). more risk oriented than betting on earlier races
By contrast with arousal and personality (Bird & McCrae, 1985). Recently, Ladouceur,
theories, cognitive theories of gambling assume Giroux and Jacques (1998) showed that regular
that the acquisition of wealth is the primary punters, defining themselves as experts in horse
motivation involved, and that people do not races, could not provide a better rate of return
behave as they normally would with respect to than a random selection of horses.
that motivation. According to cognitive the- In games of chance all alternatives have equal
ories, gamblers hope to win money or believe expectations, and thus there is no optimal
that they will win money. Why people should method of play. Well known games of chance
hope to win or expect to win in the face of the include lotteries, roulette, and slot machines.
adverse odds involved is the central concern of Since no optimal strategy exists for games of
such theories. chance, players would be expected to expend no
effort in trying to choose the best actionÐthe
most likely winning ticket in lotteries, the most
6.26.3 DEPARTURES FROM NORMATIVE likely winning number in roulette, or the
DECISION MAKING IN GAMES OF machine most likely to pay out in slot machines.
SKILL AND GAMES OF CHANCE Nevertheless, players can be observed expend-
ing considerable effort in making these decisions
Some gambling games allow the players a (Griffiths, 1994; Wagenaar, 1988; Walker,
range of decisions which can affect the out- 1992). To the extent that players believe that
comes. In such games, players may depart from some alternatives are more likely than others in
optimal play by choosing alternatives with games of chance, their approach to betting can
lower expected values. Skill then refers to the be regarded as not normative.
extent to which a player's strategy of choices
approaches the optimal strategy. Gambling
games involving skill include blackjack, poker, 6.26.4 DEVELOPMENT OF GAMBLING
and sports betting. In all of these games, PROBLEMS
systematic departures from optimal play have
been reported. Although a wide range of gambling-related
In blackjack, with optimal play, the expected problems have been documented (Walker,
value of casino blackjack is approximately 1992), the classification of such problems has
70.7% with variations from that figure depend- not been adequately developed. Classification
ing on the specific rules of play that apply. of gambling problems can proceed from
Nevertheless, most players do not approach this different perspectives and be based on different
Development of Gambling Problems 591
criteria. Most commonly, gambling-related employment. Thus, to the group of spouses that
problems are classified by the area in the includes ªgolfing widowsº and ªfishing wi-
gambler's life that is affected. Thus, Dickerson dows,º should be added ªgambling widows.º
et al. (1995) divided gambling problems into The impact on the family of excessive involve-
those associated with the individual, the family, ment in leisure activities or employment is
financial status, employment, and criminal common across activities and may be a cause of
activity. Lorenz and Shuttleworth (1983) div- family argument and distress. However, it is
ided the problems into personal, relationship, likely that time away is for most gamblers and
and financial. Similarly, Custer and Milt (1985) their families a minor factor compared to the
divided the problems into gambling, alienation, financial losses suffered by the persistent
marital problems, boredom, legal problems, gambler.
indebtedness, needs, and goalessness. Categor- Apart from the loss of time and money, there
ization of problems in this way has value at the is one further area of loss that is more difficult to
level of assessment, but does not clarify the quantify. Gambling can be characterized as a
nature or source of the problems. Although background of failure broken only by occa-
overlaps must exist, it remains possible for a sional success. According to cognitive accounts
new researcher to divide the gambling-related of persistence with gambling, the gambler holds
problems differently into another, possibly a set of erroneous beliefs about the nature of
equally useful, set based on areas affected. gambling and the role of the gambler in relation
An alternative approach, which places more to the gambling. Persistence with gambling
emphasis on the genesis of the problems, increases the likelihood of overall loss. Thus the
assumes that the main cause of the problems gambler is continually engaged in searching for
is persistence with gambling despite the losses. explanations that maintain the core beliefs. The
Cognitive theories seek to explain why the mass of evidence suggesting that the gambler's
gambler may persist with gambling until the beliefs are erroneous is a continuing stress that
losses become excessive. The next step in can be expected to cause loss of self-esteem and,
understanding problem gambling, which ulti- ultimately, depression. It would not be surpris-
mately becomes labeled ªpathological,º in- ing to find that some gamblers show evidence of
volves analyzing the consequences of extreme this stress in aspects of their physiology and
persistence in the face of large losses. The biology (Blaszczynski, Winter, & McConaghy,
central consequence, and possibly the core 1986; Carlton & Manowitz, 1987; Sharpe et al.,
factor in causing gambling problems, is the 1995).
financial loss. Although it may seem obvious One problem that general theories of gam-
that financial loss is a fundamental aspect of bling must confront involves specifying why
gambling problems, this perspective is some- only a minority of regular gamblers suffer
times not given the emphasis that would seem problems to the extent that they ultimately seek
appropriate. For example, only four of the 10 counseling and treatment. Individual differ-
criteria defining pathological gambling in the ences in persistence with gambling have been
Diagnostic and statistical manual of mental explained in terms of personality differences
disorders (4th. ed.; DSM-IV; American Psy- (Zuckerman, 1979), biological differences (Ja-
chiatric Association [APA], 1994) explicitly cobs, 1986), and learning differences (Dick-
refer to the loss of money and the problems erson, 1984). However, perhaps the most
caused thereby. If the financial cost of gambling valuable insights concerning individual differ-
is emphasized, then many of the criteria for ences in gambling have been provided by Orford
identifying pathological gambling can be under- (1985) and Oldman (1978). Orford asked the
stood as consequences of this common cause. important question as to why not all gamblers
Walker (1992), in his description of a socio- continue gambling until their money is ex-
cognitive theory of gambling, shows how the hausted. If gambling is intrinsically rewarding,
false beliefs of gamblers can lead to chasing progression to gambling problems and pathol-
losses, changes in mood, withdrawal and ogy would be expected. Yet the majority of
secretiveness, deceitfulness, irritation and an- gamblers control their gambling sufficiently to
ger, and foolish financial transactions. These avoid the potential problems. Thus, inability to
changes at the individual level, coupled with the exercise control over the desire to gamble is an
large loss in income, would be expected to important aspect of the genesis of gambling
impact on the family life, employment, and problems. Orford suggests that gambling pro-
social life of the gambler. blems may involve the conjunction of excessive
Persistence with gambling causes not only appetites, incomplete socialization of control
financial loss, but also absorbs large amounts of over appetites, and the availability of opportu-
the gambler's time. The time away can be nities to gamble. Evidence for such a view of
expected to impact heavily on the family and on gamblers comes from observational studies of
regular gamblers that show that most are able to (Ladouceur, Arsenault, DubeÂ, Jacques, & Free-
modify their approaches to gambling when ston, 1997), superstitous behavior (Ladouceur,
demanded by changed financial circumstances Giroux, & Jacques, 1988), and problem solving
(Rosecrance, 1986). Oldman (1978) took the abilities. The interview is divided into two
argument one step further by pointing out that sections and covers the following aspects: history
gambling problems were a natural consequence of the gambling activities; motivation for the
of persistence with gambling. The label ªpatho- consultation; first contact with gambling; first
logical gamblingº may thus be a means by which problems with gambling; familial, professional,
society negotiates the counseling and treatment and marital problems; money lost and criteria of
of gamblers who are sufficiently unlucky that pathological gambling. The last step in our
they lose too much (Oldman, 1978; Walker, evaluation is the second administration of the
1995). DSM-IV in order for the therapist to confirm
the diagnostic of pathological gambling. If the
individual is diagnosed as a pathological
6.26.5 DEFINITION AND ASSESSMENT gambler, treatment is offered and usually starts
OF PATHOLOGICAL GAMBLING the next session after the evaluation procedure.
This procedure has many advantages. First,
Pathological gambling was officially recog- the gambler is contacted within the 24 hours
nized in 1980 with the publication of DSM-III after his call. Second, the telephone interview
(APA, 1980), and was classified as an impulse focuses on the gambling problem (description of
control disorder. The DSM-IV (APA, 1994) the main complaints and the administration of
defined 10 criteria reflecting different aspects of the SOGS), thus setting the purpose of the
pathological gambling. To assign the diagnostic consultation and the subject matter of further
of pathological gambling, the individual must treatment, if necessary. Third, this assessment
meet at least five of these criteria. As mentioned procedure provides relevant information about
above, if most individuals gamble without it the different aspects of the gambler's life
being a problem, some will eventually become problems (family, job, social, legal, financial,
overwhelmed by the desire to gamble, will etc.). Fourth, this procedure will provide useful
gamble more than they planned, and will data for the validation of various instruments,
eventually spend more money than they can and on the characteristics of the patients who
afford to lose. Pathological gambling is char- refuse or drop out of treatment. As will be
acterized by a loss of control over gambling, lies discussed later, adherence to treatment is a
about the extent of involvement with gambling, major concern for professionals working with
family and job disruption, stealing money, and pathological gamblers. We need to identify the
continuous chasing of losses. From a clinical characteristics and the reasons of individuals
perspective, two elements are the most repre- who refuse treatment, drop out, or simply do
sentative of a pathological gambler: continuous not show up for the first session.
or obsessional chasing of losses; and family, job,
and social disruption caused by gambling.
In our clinic (R. L.), we have recently adopted 6.26.6 PREVALENCE OF
a multistep evaluation procedure. When an PATHOLOGICAL GAMBLING
individual calls for help for a gambling problem,
we return the call within 24 hours. During this The prevalence of pathological gambling is
first call, we ask the gambler to describe his main the percentage of the members of a society at a
complaints and then administer the South Oaks given point in time whose gambling is patho-
Gambling Screen (SOGS). The SOGS is a 20 logical according to some agreed criterion.
item instrument used in many prevalence studies Nearly all studies of the prevalence of patho-
around the world to identify the number of logical gambling have used one or other of the
pathological or problem gamblers in the general two measures described: the DSM-IV criteria
population. It has been translated into many and the SOGS. Most of the research has been
languages including French, Chinese, German, conducted in the USA by Rachael Volberg on a
and Spanish. If preliminary data collected state by state basis (Volberg, 1996), although
during the phone call suggests that the individual substantial numbers of studies have been
is a pathological gambler, a formal semistruc- conducted outside the USA, such as in Canada
tured interview is immediately scheduled in (Ladouceur, 1996), Spain (Becona, 1996),
order to identify the nature and history of the Australia (Dickerson, Baron, Hong, & Cottrell,
problem. Before starting this interview, the 1996), and New Zealand (Abbott & Volberg,
individual will be asked to complete question- 1996).
naires evaluating the following areas: depres- Comparison of the data from the studies
sion, anxiety beliefs about gambling reviewed by the authors listed above is made
Psychological Treatment of Pathological Gamblers 593
difficult by the fact that the details of the designs maintain an unrealistic hope that they will
varied considerably across research groups. recover their losses if they persevere with the
Volberg and Ladouceur used telephone surveys, gambling. It is assumed that their erroneous
whereas the surveys in Spain, Australia, and beliefs about gambling, about the nature of
New Zealand used door knock surveys. Becona predictability, and about their own special skills
used DSM-III-R criteria whereas other re- and knowledge in relation to predicting gam-
searchers based their conclusion on the SOGS. bling events, conspire to maintain the gambling
Although most research has adopted a cut-off far beyond any reasonable limits. It follows that
of five on the SOGS for the identification of any correction of erroneous perceptions weak-
pathological gamblers, Dickerson has argued ens the belief that losses can be recouped.
that the cut-off should be higher. Finally, the However, alternative approaches to the treat-
SOGS itself may not be a sufficiently accurate ment of pathological gambling are not based on
indicator of pathological gambling for use in the these assumptions. There are in fact two main
prevalence research (Walker & Dickerson, alternatives to the erroneous thinking ap-
1996). Thus, current estimates of the prevalence proach: (i) the behaviorist orientation, based
of pathological gambling must be treated with a on the use of extinction processes; and (ii) the
degree of caution. Nevertheless, the available problem solving approach where the gambler is
evidence suggests that the occurrence of counseled in methods appropriate to solving
pathological gambling varies from country to problems causing the gambling. Both orienta-
country. Walker and Dickerson note that the tions assume that the central motivation is not
prevalence figures for pathological gambling avarice, but some other factor altogether. These
are correlated with the average expenditure on two approaches differ in the level at which they
gambling across countries. Thus, in countries in assume the relevant processes are operating:
which a higher percentage of personally ex- molecular and below awareness for the beha-
pendable income is spent on gambling, there is a vioristic approach; conscious planned processes
higher reported prevalence of pathological in the problem solving approach.
gambling (Table 1). The behavioral approach assumes that
Evidence of this kind strengthens the argu- gambling-based arousal is the central factor
ment that gambling-related problems are pri- in the reinforcement process. It is assumed that
marily associated with the loss of excessive the increase in arousal associated with gambling
amounts of money. Theories of pathological is positively reinforcing. With repeated gam-
gambling must explain why the gambler persists bling a whole range of associated stimuli
in gambling despite such losses. Cognitive become conditioned reinforcers. Approach to,
theories assume that it is erroneous beliefs and participation in, gambling in regular
and inferences about gambling and the like- gamblers are triggered by a wide range of
lihood of favorable outcomes which maintains environmental features: the sight of the news-
the behavior in the face of serious monetary paper, driving the car, leaving work, the sight
losses. It follows that a cognitive approach to of money in the wallet, and so on. The wide
therapy is the one that will attempt to correct the range of factors associated with gambling is
erroneous thinking involved. often referred to, at the macro level, as
preoccupation with gambling. Treatment
makes use of established learning theory
6.26.7 PSYCHOLOGICAL TREATMENT
principles involving extinction of the associa-
OF PATHOLOGICAL GAMBLERS
tion between arousal and central conditioned
The central assumption of cognitive ap- elicitors. The most effective specific treatment
proaches to treatment is that the pathological program using the behavioral approach appears
gambler continues to gamble because they to be imaginal desensitization (McConaghy,
Table 1 SOGS scores and gambling expenditure across countries.
Country SOGS scores Expenditure on gambling

(% scoring 5+) (% of personal consumption)c
Australia 7.1 1.6

New Zealand 2.7 0.9
Spain 1.5a 0.7
Canada 1.2b 0.5
a b
Means of estimates provided by Becona. Ladouceur's data only. cHaig (1985).
Armstrong, Blaszczynski, & Allcock, 1983; Ladouceur and his colleagues in Canada
Blaszczynski, McConaghy, & Frankova, suggests that the core cognitive error lies in
1991). Imaginal desensitization involves creat- the gambler's notions concerning randomness.
ing a list of specific gambling triggers for the The illusion of control and belief in the
individual. The gambler is taught standard predictability of events that depend on the
muscle relaxation techniques. Finally, the misconception of randomness are assumed to
gambler is asked to imagine the trigger situa- lead ultimately to the bizarre beliefs documen-
tions one by one, each time accompanied by the ted by Coventry (1997), Walker (1992), and
relaxation procedure. In this way, the associa- others. Gamblers try to control and predict
tion of arousal with each of the triggers is outcomes of games that are objectively un-
extinguished. McConaghy, Blaszczynski and controllable. The illusion of control motivates
co-workers treated 60 pathological gamblers them to elaborate strategies to win more money.
with the imaginal desensitization procedure, However, all gambling is based on the inherent
and a further 60 pathological gamblers by a unpredictability of gambling events either
range of other techniques (aversion therapy, through inadequate information, as in sports
relaxation therapy, and cue exposure). Of the 60 betting, or through the incorporation of
pathological gamblers treated by imaginal randomness as in slot machines, casino games,
desensitization, only 33 could be followed up and lotteries. It follows that if the erroneous
two or more years later. However, of these 33, perceptions and understanding of randomness
26 (79%) were gambling in a controlled way or in the gambler can be corrected, then the
not at all. In the control group, only 16 (53%) of motivation to gamble should decrease drama-
the 30 followed up had achieved control or tically. Our treatment programs have focused
abstinence. on erroneous cognitions concerning random-
The problem solving approach refers to a ness as the most important targets for change.
general orientation towards treatment rather The whole range of erroneous cognitions,
than a coherent orientation towards the causes sometimes labeled ªirrational thinkingº and
of pathological gambling. The actual causes of which constitute the illusion of control, are also
the gambling are assumed to be a variety of important targets for change. Since persistent
factors determined primarily according to the gambling induces a range of other problems
implicit theories of the counselor. According to these are also treated. The loss of money is
addiction counselors, the gambler is driven by associated with many of these problems.
intense urges to gamble repetitively and in a Training in problem solving techniques appears
maladaptive way. Thus the problem solving to be appropriate and necessary in some cases.
approach is oriented to increasing the gamblers Also, many gamblers often lie and isolate
ability to cope with the urges and to provide themselves in order to gamble, and so social
action alternatives that can be used to redirect skills training may be necessary to help the client
the energies involved into alternative less to reestablish adequate social relationships.
hazardous directions. Many counselors believe In order to evaluate the effectiveness of
that the gambling is an escape from crises and cognitive theory for pathological gambling, a
dilemmas which cause the individual great controlled study has been undertaken at Laval
anxiety. Thus the problem solving approach is University. Four components were included in
oriented to dealing with these other issues for the therapy: (i) cognitive correction; (ii) problem
which the gambling is an escape. There is a solving training; (iii) social skills training; and
considerable body of research suggesting that (iv) relapse prevention. These components are
counseling approaches yield improvement with- now described and are followed by a case study
in a before-and-after design (Walker, 1992), which illustrates how these elements have been
little research has been done in which alternative integrated in the treatment of a pathological
therapies are compared or control groups used. gambler. Treatment is administered on an
The evidence available suggests that significant individual basis with one 60±90 minute session
improvement may occur in a group of untreated per week, over a period of 12 weeks.
pathological gamblers in a six month period
(Echeburua, Baez, & Fernandez-Montalvo,
1996). Thus the necessity for controlled trials 6.26.7.1 Changing Erroneous Beliefs
with longer-term follow ups (two years or more, Concerning Randomness
ideally) is apparent.
The cognitive approach to the treatment of Correction of the misunderstanding of ran-
gambling is based on experimental work domness is the first goal of the treatment.
demonstrating a wide range of cognitive errors Different approaches to this task are possible
made by gamblers in relation to gambling according to the characteristics of the individual.
(Ladouceur & Walker, 1996). The research of However, only the general guidelines will be
Psychological Treatment of Pathological Gamblers 595
described here. First of all, most gamblers are attention to the specific strategies that imply a
not aware of their erroneous perceptions of sequential relationship between outcomes or
randomness. They spontaneously deny that they that the probabilities of specific outcomes can
maintain such false conceptions. Increasing be altered. The therapist should focus attention
awareness of the actual way in which gambling on any verbalizations made by the gambler that
events occur is a first step in enabling gamblers to suggest the existence of links between the
recognize their misconceptions concerning the outcomes of the games. We often tape record
predictability of the game (Ladouceur & DubeÂ, these sessions in order to capture and analyze all
1997; Ladouceur, Paquet, Lachance, & DubeÂ, of the patient's verbalizations suggesting links
1996). The patient will be asked to describe the between the outcomes of the games. This
evolution of their gambling habits, how they recorded material is used to increase the
were betting at first, the changes in their betting patient's awareness, and later on to correct
as they became more familiar with the games, faulty perceptions.
and to what extent they feel they have some Another useful way to illustrate the erroneous
potential control over certain games. By asking links inferred between events is by tossing a coin
about the way to get an edge in the particular with the patient. First the patient is asked to
form of gambling involved, the gambler is predict whether the next event will be ªheadsº or
invited to expose some of their errors in thinking. ªtailsº and to explain and justify his choice
Inevitably, the gambler will describe strategies of (Ladouceur & DubeÂ, 1997). Most patients will
play which assume that there is more predict- say that their choice is based on a 50/50
ability present than is in fact the case (Ladou- probability of each possible outcome, which is
ceur, Paquet, & DubeÂ, 1996). indeed correct. This exercise is carried out a few
The therapist will ask the client to describe times in order to demonstrate that predicting
what they are saying to themselves when they heads or tails is such a simple game, and that all
gamble. In doing so, the therapist may ask the of the outcomes of the toss are independent.
patient to answer the following questions: Why Gamblers will generally agree with the thera-
did you place one particular bet instead of pist. Then, in order to demonstrate the presence
another? How did you determine this bet? Are of erroneous cognitions during a gambling
you trying to control the game by avoiding session, a simple test is performed.
certain bets? Would you agree to switch poker The therapist writes down six consecutive
machines in the middle of a session when the outcomes of heads and covers them with a piece
machine you are playing has not paid out for a of paper. Once again, the patient is asked to
long time? Would you agree to bet on any predict the outcome of the next toss. After their
number at the roulette table? How did you pick choice has been made, the six previous out-
the numbers that you did on the lottery ticket comes are revealed and the patient is asked if
you bought this week? The main goal of these they would like to change their prediction
questions is to clarify the fact that the gambler is before the coin is tossed again. Whether they
using some sort of information to predict an change their prediction or not, patients will
event which is independent of all other events examine this series of outcomes. The therapist
and essentially unpredictable beyond its chance then points out the fact, that although the
probability. gambler knew that every outcome of a coin toss
The therapist makes a distinction between is independent, they spontaneously examined
gambling that involves events that are inher- past outcomes even though these are completely
ently unpredictable because of inadequate irrelevant. This simple behavioral exercise has
information (such as horse racing) and events proven to be very helpful for demonstrating to
which are random (such as lotteries or slot the patient how this tendency to link irrelevant
machines). The therapist then shows that events is very powerful. (Ladouceur & Walker,
inherently unpredictable events are essentially 1996, give an extensive discussion of this
the same as random events. Then, explanation phenomenon.)
of the concept of randomness follows, focusing The notion of randomness is then explained
on the most crucial element: each turn is an in detail, illustrated by examples of the games
independent event (Gaboury & Ladouceur, played by the patient. The fundamental error is
1989; Walker, 1992). Since each event is in believing that information may be used to
independent, there can be no influence from establish links between outcomes and then used
one event to the next and no predictability to place winning bets. Gamblers will erro-
across events. Furthermore, as the events neously perceive some elements of skill that, if
cannot be influenced legally, there can be no used appropriately, enhance their probability of
strategies to control the outcomes of the game. winning. This illusion of control explains why
The therapist will focus on the strategies used by people bet more money as they become more
the gambler in their preferred game, and draw familiar with a game, firmly believing that they
have developed some skills that can be used 6.26.7.2 Problem Solving Training
profitably. During this first stage of treatment, it
is brought to the patient's attention that in many Problem solving training is a second thera-
studies, conducted with different games in peutic intervention, used if the gambler shows
different countries, more than 75% of the poor problem solving skills when coping with
players' verbalizations are erroneous (Ladou- excessive gambling activities. Problem solving
ceur & Walker, 1996). Literature detailing the training becomes an integral aspect of the
frequent misconceptions of gamblers is also treatment of the pathological gambler if the
provided to the client. therapist and the patient identify that additional
The pathological gambler is then asked to skills are needed to solve the actual problems
identify their own erroneous perceptions. This is related to excessive gambling. The therapist will
achieved through a variety of methods such as: introduce a problem solving technique (Gold-
asking the patients to describe what they are fried & Davison, 1976) that involves the
saying to themselves when gambling (see following five steps: (i) defining the problem,
example below); simulating a game and having (ii) collecting information about the problem,
the gambler describe how they proceed in (iii) generating different solutions, (iv) listing
choosing their bets; and asking the patient to advantages and disadvantages for each solu-
imagine a gambling session and describe out tion, and (v) implementing and evaluating the
loud what they are thinking, using the ªthinking solution. The patient learns how to cope with
out loud methodº (Gaboury & Ladouceur, the difficulties related to gambling. For exam-
1989). These sessions are also usually recorded. ple, in order to have better control over
Some examples of erroneous cognition are: ªIf I spending, they may decide to pay their bills
lose four times in a row, I will win the next immediately after they are issued, create a
time,º or, after one or two wins, ªI am really budget, and carry only the amount of money
getting better at this game, I know how to bet.º they need.
We will often start by replaying the tape
obtained within an earlier treatment session, 6.26.7.3 Social Skills Training
to demonstrate to the clients their false beliefs
about the notion of randomness. The clients will If necessary, gamblers are also given social
also be asked to listen to the tape at home and skills training in order to improve their social
identify every erroneous perception, or irra- competence. The potential link between poor
tional statement. It is important to note that the social skills and gambling activities is discussed
basic cognitive error involves the linking of with the patients. It is important to recognize
independent events. that pathological gamblers may need more than
Finally, the last phase involves the correction usual social skills to deal with their relationship
of inadequate verbalizations and faulty beliefs. conflicts. For example, some gamblers needed
Patients will monitor their own verbalizations assertiveness training in order to increase their
when they are thinking about gambling, when ability to refuse invitations to gamble with
they have the urge to gamble, or when they are friends. Role playing can be used to improve
gambling if they have not yet stopped. The communication skills. This training focuses on
patients will (i) identify erroneous perceptions, the negative consequences of gambling and how
(ii) evaluate and challenge the adequacy of these the lack of good social skills is a contributing
perceptions, (iii) replace these inadequate factor.
cognitions by adequate verbalizations, and
(iv) assess the strength of their belief in the 6.26.7.4 Relapse Prevention
new cognitions. The recording of their own
verbalizations made during a simulated gam- Relapse prevention is based on and adapted
bling session may be used during this corrective from the relapse prevention model developed by
phase by asking the patient to reformulate Marlatt (1985) for alcoholics. The possibility of
erroneous perceptions by an adequate verbali- relapsing is always discussed with the partici-
zation. The success of this phase is normally pants. They learn to become aware of high risk
required before addressing further issues. Our situations (present or past) and the reasons why
clinical experience and empirical data (see people return to gambling. Patients will describe
below) support the fact that other therapeutic their relapses, identify high-risk situations, and
components are likely to be unsuccessful unless develop specific ways to deal with the situations.
the gamblers have developed an adequate For example, carrying cash (as on pay days),
conception of the notion of randomness and stress, loneliness, and lack of social activities are
can apply this notion to their own behavior. If common high-risk situations. Each situation is
the illusion of predictability in gambling events discussed in terms of the erroneous perceptions
is allowed to remain, relapse is likely to occur. associated with gambling. Specific attention is
Efficacy of a Cognitive/Behavioral Treatment for Pathological Gamblers 597
drawn to the debt and to the likelihood that the 6.26.8.1 Case History
debt will be increased if gambling is resumed.
Peter is 43 years old, married, and the father
of two adolescents. He is currently working as a
6.26.8 EFFICACY OF A COGNITIVE/ civil servant. He has been playing video poker
BEHAVIORAL TREATMENT FOR for four years. At the time of his consultation, he
PATHOLOGICAL GAMBLERS was playing three times a week on average,
which resulted in monetary losses of $350±500
Single case experimental studies have been per week (Canadian).
conducted over several years to evaluate the Peter started gambling when two of his
cognitive/behavioral approach to treatment for colleagues invited him for a drink after work.
adults and adolescents suffering from patho- As soon as they entered the bar, the two
logical gambling. The results were quite encour- colleagues, both video poker players, showed
aging (Bujold, Ladouceur, Sylvain, & Boisvert, Peter how to play the game. After an initial bet of
1994; Ladouceur, Boisvert, & Dumont, 1994). $10, Peter won $125. During the following
The following control group comparison study weeks, he developed an interest for video poker
was conducted to further assess the treatment's and played often. He occasionally made sig-
efficacy (Sylvain, Ladouceur, & Boisvert, 1997). nificant wins, and started believing that video
Twenty-nine pathological gamblers partici- poker was a good way to make money. After six
pated in the study. The majority of gamblers months, his gambling became so intense that he
were video poker players, whereas others had to use his personal credit and borrow money
gambled on horse races or casino games. to cover his losses.
Subjects were randomly assigned to a treatment He progressively became obsessed with
or a waiting list control group. gambling. He accumulated increasing debts
The following dependent variables were used: and was constantly preoccupied by the need to
(i) DSM-III-R; recover his money. He neglected his wife and
(ii) SOGS; children more and more each day. He lost his
(iii) perception of control over the gambling motivation to work, he often arrived late after
problem rated on a scale of 0±10; having spent the lunch hour gambling or, he left
(iv) desire to gamble indicated on a 0±10 early in the afternoon in order to play. His
scale; spouse did not know about her husband's
(v) self-efficacy perception evaluating their gambling habits. She began to worry about his
belief that they could refrain from gambling in repeated lateness in the evening and his
high risk situations; incapacity to pay the bills before the due date.
(vi) frequency of gambling in terms of the She questioned and doubted Peter's justifica-
number of gambling sessions, the number of tions for his prolonged absences. Tension and
hours spent gambling, and the total amount of conflicts became commonplace within their
money spent on gambling during the previous relationship. Peter's urge to play increased with
week. his need to recover the lost money so that he
Results showed that treated subjects improved could pay his bills, and in order to escape the
significantly compared to the control group. climate of tension reproaches in his relationship
Treated individuals met fewer diagnostic criter- with his wife.
ia, reported less desire to gamble, and had a After four years of excessive gambling, the
lower SOGS score. They also reported a losses were enormous. His absences from home
significantly higher perception of control and became no longer justifiable and lying was
self-efficacy. In order to provide clinically frequent. One day, his boss, worried about
relevant results, the percentage of change and Peter's diminished productivity, asked him the
end state functioning (comparing post-test reasons for this change. Confronted with the
scores to a criterion score) were calculated. possibility of losing his job, Peter had no choice
Among the treatment group, 12 of the 14 but to admit that he had a gambling problem. He
participants improved by 50% or more on three also decided to tell everything to his wife.
dependent variables, and on the end state Finally, he decided to seek treatment. A
functioning criteria, in comparison to one of diagnostic of pathological gambling was made
the 15 participants in the control group (85% by the therapist and confirmed by a second
success rate). Finally, six and 12 month follow- experienced therapist who listened to a tape of
up measures indicated that the therapeutic gains the first session. The goal of the first intervention
were still present, confirming the long-term was to evaluate his motivation to change. Peter
effects of this therapeutic program. The follow- listed the advantages of stopping gambling and
ing case study illustrates the procedure de- the negative consequences the game has had on
scribed above. his life. Monetary losses, professional and
marital problems, and stress were examples of question his gambling habits (e.g., ªWhy do I
the negative consequences. Also, the return to a feel like playing?º ªI want to make money . . . is
normal financial situation, general well-being, this realistic?º ªWhat could happen to me if I
and better relationships with the people around play? I risk further loss.º ªAnd if I lose, what
him were the main advantages formulated by will happen? I want to recover my money.º
Peter to stop gambling. ªCan I really win?º ªEven if I win tonight, it will
never be enough to compensate for all the
money I have lost.º ªThe longer I try to win, the
6.26.8.1.1 Identification and correction of faulty
more likely I am to lose.º).
cognitions toward gambling
Considering that one of Peter's motivations
6.26.8.1.2 Problem solving and social skills
to gamble was to make money rapidly, it was
training
important to provide him with factual informa-
tion concerning gambling, and to identify his This component was used to modify behav-
erroneous cognitions. The therapist asked him iors related to excessive gambling. Peter men-
to imagine his last gambling session and try to tioned going to the bank machine to check how
identify his thoughts and the triggering events. much money he had left in his banking account.
Peter reported the following sequence. He left This compulsive checking triggered cognitions
the office and drove toward his usual gambling related to his lack of money, and the need to win
place instead of going home as he had initially more and gamble. Peter became aware of the
planned. He reported having this reaction sequence of these behaviors and realized the
instantly, without thinking, as if someone had links between this checking behavior and his
told him what to do. The therapist had Peter gambling activities. He resolved to stop check-
focus his attention on the sequence of events ing his banking account. Peter also had to
that took place immediately before leaving his modify other relevant behaviors that stimulated
office. He was asked to remember what was gambling such as keeping less cash money with
going on and what he was thinking at that him, not carrying his banking and credit cards,
specific moment. Peter remembered putting his and avoiding bars with video poker machines.
documents in order and, by accident, seeing the Finally, the involvement with new activities,
bills for his credit card that were overdue. The such as sports and family activities, helped Peter
therapist inquired about the thoughts asso- to reorganize his timetable and to replace the
ciated with finding unpaid bills. Peter answered time spent gambling with less financially
that he suddenly felt panic and became very damaging activities.
tense. When thinking back on the feeling of
panic, he identified the links between this feeling 6.26.8.1.3 Relapse prevention
and his unpaid bills. Peter panicked because he
did not have the money to pay his bills. This By learning to identify situations with a high
made him so uncomfortable that he wanted to risk of triggering a relapse, and by analyzing
get money to pay them as fast as he could. The situations which led him to gamble, Peter
therapist finally asked him what he said to developed cognitive and behavioral strategies
himself following this discomfort, and how was needed to refrain from gambling.
he going to solve his problem of obtaining
money? At that moment, Peter became aware 6.26.9 EVALUATION OF A COGNITIVE
that he strongly believed that the best way to get TREATMENT FOR
a lot of money in a short period of time was by PATHOLOGICAL GAMBLING
gambling. He realized that this was his motiva-
tion to gamble on this last occasion. Following the positive results obtained
The therapist discussed the probabilities of through this controlled study, it was decided
winning, and the negative monetary expectan- to evaluate the specific role of correcting the
cies of the games which would inevitably result fundamental cognitive error about the notion of
in losses in the long run. The therapist explained randomness. From a theoretical and clinical
that no strategies could be used by the player to perspective, it was believed that this component
win, and that the urge to recover the lost money was the crucial variable in the maintenance of
was, in fact, just an illusion that leads to a excessive gambling. The efficacy of a cognitive
vicious circle which can only end in loss. By treatment for pathological gamblers was as-
questioning and confronting Peter's erroneous sessed based on the correction of erroneous
cognitions over several sessions, he started to cognitions concerning the notion of randomness
realize that thinking he will win money is not and, more specifically, through the modification
realistic. Peter learnt to replace erroneous of the gambler's tendency to link independent
cognitions with appropriate ones, and to events when gambling.
Concluding Remarks 599
Five pathological gamblers from the popula- There are no obvious solutions to these matters.
tion described above participated in this study Our clinical experience has led to the develop-
(Ladouceur, Sylvain, Letarte, Giroux, & Jac- ment of a series of procedures used to improve
ques, in press). A single case experimental treatment compliance.
design across subjects was used to assess the First of all, when an individual contacts us,
efficacy of the treatment. Cognitive correction we return the call within 24 hours, conduct a
included four components: brief telephone interview, and administer the
(i) Understanding the concept of SOGS. If the individual appears to be a
randomnessÐthe therapist explains the concept pathological gambler, an appointment is sched-
of randomness, independence among events, uled within a week at which point we conduct a
the impossibility to control the game. structured interview and administer a series of
(ii) Understanding the gamblers' erroneous questionnaires. If therapy is undertaken, the
cognitions, mainly the difficulty to apply the therapist will inform the patient that compli-
principle of independence among events. The ance is a major difficulty for pathological
therapist explains how the illusion of control gambling and explore ways to overcome this
contributes to the maintenance of gambling problem. Furthermore, the patient will sign a
habits. contract indicating that they agree to participate
(iii) Awareness of inaccurate perceptions. for at least 10 sessions, and that if they are
(iv) Cognitive correction of erroneous per- unable to attend, they will call ahead of time to
ceptions. cancel the session, that they will pay one session
The dependent variables were the same in advance, and that after two nonmotivated
measures used in the study described pre- absences, treatment will be terminated.
viously. Results indicated that all subjects, A second difficult issue is determining
except one, increased their perception of control whether the goal of the treatment should be
and reduced their urge to gamble, thus support- controlling the gambling or abstinence. Many
ing the prediction that a cognitive treatment, pathological gamblers ask that the goal of
based on the correction of erroneous perception treatment be controlled gambling. Some will be
about the notion of randomness, decreases very convincing and will put forth appropriate
pathological gambling. The treatment outcome and rational arguments. We have often caught
of this intervention provided positive results ourselves spending many sessions discussing
equivalent to those obtained by a multicompo- this difficult subject without finding a solution.
nent intervention. Therefore, cognitive correc- Gamblers suggest that controlled gambling is
tion of erroneous perceptions toward the notion the main goal, simply because they cannot see
of randomness is likely to be the key element in themselves abstaining from this activity, or
the treatment of pathological gambling. We are simply because they are not ready to stop
now replicating this study with a greater gambling. Our approach on this matter is to
number of subjects, using a controlled group consider abstinence as the main goal, and then
comparison design. In conclusion, these thera- once it is achieved, the matter can be recon-
peutic interventions, with an 85% success rate, sidered. In a few cases, instead of losing the
open new avenues for the treatment of patho- patient, we have accepted controlled gambling
logical gambling. as the main goal of treatment. However, this
solution should never be accepted except as a
last option.
6.26.10 COMMON DIFFICULTIES IN THE The third difficulty is identifying erroneous
TREATMENT OF perceptions towards the notion of randomness
PATHOLOGICAL GAMBLERS as discussed above. Often, pathological gam-
blers will simply deny that they have these
Clinicians who have treated pathological misconceptions. The best way to pursue this
gamblers have been confronted with a number matter is to design some behavioral experiment
of difficulties. We will briefly mention the most to facilitate the identification of erroneous
common and difficult ones encountered over perceptions. Gamblers deny these perceptions
the years in our clinic where approximately 200 because they are not aware of them.
pathological gamblers have been interviewed.
The first and most important issue is treatment
compliance. Very often, individuals will ask for 6.26.11 CONCLUDING REMARKS
an appointment but, without canceling, will not
show up. They frequently drop out after one or This account of pathological gambling takes
two sessions, or will simply decide to terminate a cognitive perspective. It is assumed that
treatment after a few weeks of abstinence, pathological gambling occurs when the gambler
thinking that their problem has been solved. persists in gambling, despite the losses involved,
believing that ultimately the losses will be Coventry, K. R. (1997). Rationality and decision making:
recovered and money will be won. These false The case of gambling and the development of gambling
addiction. The proceedings of the Ninth International
beliefs of the gambler are maintained by the Conference on Gambling and Risk Taking, Las Vegas,
inadequate knowledge of the probabilities of NE, 1994.
success and the erroneous interpretation of the Custer, R. L., & Milt, H. (1985). When luck runs out. New
notion of randomness. If this account of the York: Facts on File Publications.
Dickerson, M. G. (1984). Compulsive gamblers. London:
motivation to gamble is correct, then it follows Longman.
that pathological gambling can be treated Dickerson, M. G. (1993). Internal and external deter-
effectively by correcting erroneous beliefs of minants of persistent gambling: Problems in generalizing
the patients. This chapter presents data sup- from one form to another. In W. R. Eadington & J. A.
porting this theoretical position. Cornelius, (Eds.), Gambling behavior and problem gam-
bling. Reno, NV: Institute for the study of gambling and
commercial gaming.
Dickerson, M. G., & Adcock, S. (1987). Mood, arousal and
cognitions in persistent gambling: Preliminary investiga-
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6.27
Sexual Problems: Dysfunction
W. P. DE SILVA
Institute of Psychiatry, University of London, UK
6.27.1 SEXUAL DYSFUNCTION 604

6.27.2 CLASSIFICATION AND DIAGNOSTIC ISSUES 604
6.27.2.1 Sexual Desire Disorders 605
6.27.2.1.1 Hypoactive sexual desire disorder 605
6.27.2.1.2 Sexual aversion disorder 605
6.27.2.2 Sexual Arousal Disorders 605
6.27.2.2.1 Female sexual arousal disorder 605
6.27.2.2.2 Male erectile disorder 605
6.27.2.3 Orgasmic Disorders 605
6.27.2.3.1 Female orgasmic disorder 605
6.27.2.3.2 Male orgasmic disorder 605
6.27.2.3.3 Premature ejaculation 605
6.27.2.4 Sexual Pain Disorders 605
6.27.2.4.1 Dyspareunia 605
6.27.2.4.2 Vaginismus 605
6.27.3 ETIOLOGICAL FACTORS 605
6.27.4 ASSESSMENT OF SEXUAL DYSFUNCTION 606
6.27.4.1 Aims of Assessment 606
6.27.4.2 The Interview 606
6.27.4.2.1 Special problems 606
6.27.4.2.2 Areas to enquire about 607
6.27.4.2.3 Individual and couple interviews 607
6.27.4.2.4 Motivation and selection 607
6.27.4.2.5 Physical examination and investigations 607
6.27.4.2.6 Questionnaires and inventories 608
6.27.4.2.7 Subjective ratings 608
6.27.4.2.8 Physiological measures 609
6.27.5 FORMULATION 609
6.27.6 TREATMENT OF SEXUAL DYSFUNCTION 609
6.27.6.1 Behavioral Sex Therapy 609
6.27.6.1.1 The behavioral approach 609
6.27.6.1.2 Present-day conjoint cognitive-behavioral sex therapy 610
6.27.6.1.3 Some general considerations on therapy 613
6.27.6.2 Some Practical Issues 614
6.27.6.3 Therapy for Those Without Partners 614
6.27.6.4 Group Therapy 615
6.27.6.5 Efficacy of Therapy 615
6.27.6.6 A Note on Physical Treatments 615
6.27.6.7 Scope of Cognitive-behavioral Sex Therapy 616
6.27.7 TREATMENT ISSUES WITH SPECIAL POPULATIONS 616
6.27.7.1 The Elderly 617
6.27.7.2 Those with Physical Handicaps and Chronic Illnesses 617
6.27.7.3 Gay Clients 617
603
604 Sexual Problems: Dysfunction
6.27.7.4 Women with Eating Disorders 618

6.27.8 SUMMARY AND COMMENTS ON FUTURE DEVELOPMENTS 618
6.27.1 SEXUAL DYSFUNCTION married American couples reported sexual

difficulties, yet most were satisfied with their
The term ªsexual dysfunctionº refers to a sexual life. Similar findings have been reported
disturbance or impairment in sexual function- in a Swedish study (Nettelbladt & Uddenberg,
ing. Sexual dysfunctions are usually contrasted 1979) and a British investigation (Reading &
with sexual deviations, or called ªparaphilias.º Wiest, 1984). This highlights another key issue.
The latter are seen as a disturbance in the Sexual dysfunction is not an all-or-none affair;
direction of one's sexual interest or desire, rather there are varying degrees of difficulties. The way
than of functioning. Thus paraphilias include they are perceived varies; occasional erectile
paedophilia (sexual interest in children), fetish- failure may be seen as a perfectly acceptable
ism (sexual interest in inanimate objects), and so situation by some men and their partners, while
on. Dysfunctions, on the other hand, are failures it may bring other men to a clinic seeking help.
or problems in the actual sexual functioning, for There are also major differences in sexual
example, difficulty in obtaining an erection, or functioning in relation to age. Inability to
failure to reach an orgasm. obtain an erection increases progressively with
It must be noted, however, that there can be age (Feldman, Goldstein, Hatzichristou, Krane,
overlap and interdependence between sexual & McKinlay, 1994; Weizman & Hart, 1987). In
dysfunctions and paraphilias. A man complain- the Kinsey survey (Kinsey, Pomeroy, & Martin,
ing of erectile difficulties in coital activity with 1948), it was found that less than 1% of males
adult partners may get strong erections in had erectile dysfunction before the age of 19,
paedophiliac acts. Equally, a man presenting increasing to 25% by the age of 75.
with, say, fetishistic desires for rubber or leather
may also have erectile difficulty when he is not in
contact with rubber or leather garments (de 6.27.2 CLASSIFICATION AND
Silva, 1995). This overlap between these two DIAGNOSTIC ISSUES
types of sexual problems is important to
recognize and take into account in clinical Sexual dysfunctions have been classified in
settings. different ways by different authors in the past
A further consideration is the link between (e.g., Bancroft, 1989; Hawton, 1985), but in the
sexual dysfunction and marital or relationship 1990s a consensus has been emerging. The
problems. Both clinical and research data show current classification offered in the Diagnostic
that the two areas are often related. Rust, and statistical manual of mental disorders (4th
Golombok and Collier (1988) reported that ed., DSM-IV) (American Psychiatric Associa-
sexual dissatisfaction in the male partner tion [APA], 1994) links dysfunctions to the
strongly correlated with a poor marital relation- phases of the sexual response cycle: (i) desire
ship as perceived by both partners. The (this phase includes desire to have sexual activity
relationship between the two areas is not an and sexual fantasies); (ii) excitement (this phase
invariant one, nor is there any clear evidence of consists of a subjectively felt sense of sexual
the direction of causation when there is a link. pleasure and related physiological changes, for
The prevalence of sexual dysfunction is hard example, penile erections and vaginal lubrica-
to establish, as epidemiological studies are tion); (iii) orgasm (this phase consists of the
scarce. Masters and Johnson (1970) estimated climax or peaking of sexual pleasure, with
that half of all couples in the USA have a sexual release of sexual tension and the rhythmic
dysfunction. Spector and Carey (1990), who contraction of the perineal muscles and repro-
undertook a full review of the sexuality, ductive organs; in the male there is also
psychopathology, and epidemiology literature, ejaculation of seminal fluid, and in the female
concluded that sexual dysfunctions may be very contraction of the wall of the outer third of the
common. A major problem is that the presence vagina); and (iv) resolution (this phase consists
of a sexual dysfunction is not always distressing of a sense of muscular relaxation and general
to, or seen as a problem by, couples or well-being, in the male this also includes a
individuals. The much-cited study of Frank, physiologically refractory period in which
Anderson and Rubinstein (1978) provides some further erection and orgasm do not take place).
interesting data. Well over half the women and The dysfunctions, linked to the first three of
nearly half the men in this survey of 100 happily these phases, are classified below.
6.27.2.1 Sexual Desire Disorders 6.27.2.3.3 Premature ejaculation
6.27.2.1.1 Hypoactive sexual desire disorder Here, the essential feature is the persistent
onset of orgasm with minimal sexual stimula-
Here, there is an absence or deficiency of tion. Men with this problem reach an orgasm
sexual fantasies and desire for sexual activity. prior to, or just after, penetration, thus making
The terms ªlow libidoº and ªreduced libidoº are any meaningful coital activity impossible.
also commonly used to refer to this. Attempts to define premature ejaculation by
linking it to partner's orgasm (cf. Masters &
Johnson, 1970) is problematic.
6.27.2.1.2 Sexual aversion disorder
In this disorder, there is an aversion to, and 6.27.2.4 Sexual Pain Disorders
avoidance of, genital sexual contact with a
sexual partner. Often the aversion is focused on In addition the DSM-IV includes the follow-
a particular aspect of sexual experience. There ing:
may also be anxiety, fear, or disgust.
6.27.2.4.1 Dyspareunia
6.27.2.2 Sexual Arousal Disorders Here, there is genital pain associated with
sexual intercourse. This is most commonly
6.27.2.2.1 Female sexual arousal disorder experienced during coitus, but it can also occur
Here, there is a persistent inability to attain or before or after coitus. It can happen in both men
maintain adequate vaginal lubrication and and women, but it appears from clinical settings
vaginal expansion in response to sexual excite- that it is much more common in the latter
ment. (Bancroft, 1989; Renshaw, 1988).
6.27.2.4.2 Vaginismus
6.27.2.2.2 Male erectile disorder
This consists of the persistent involuntary
In this condition, the main feature is the contraction of the muscles surrounding the
persistent or recurrent inability to attain or outer third of the vagina when penetration is
sustain an adequate penile erection. There is attempted. When severe, it makes penetration
much variability in this. Some attain very strong impossible.
erections without being able to sustain them,
some have sustainable erections which are not Each of the above dysfunctions can be either
strong enough for penetration. Loss of erection lifelong or acquired. A lifelong dysfunction is said
during thrusting is also reported by some. to exist when the problem has been present since
the beginning of sexual functioning, for example,
6.27.2.3 Orgasmic Disorders a man who has never had an erection as an adult.
In the acquired type, the dysfunction develops
6.27.2.3.1 Female orgasmic disorder only after a period of normal functioning.
Sexual dysfunctions are also categorized into
This is also referred to as ªinhibited female generalized and situational types. In the former,
orgasm,º ªanorgasmia,º and more rarely, the dysfunction occurs in all situations, and is
ªinorgasmia.º The essential feature is the not linked to certain types of partners, situa-
persistent delay in, or absence of, orgasm tions, or stimulation. In the latter, the dysfunc-
following a normal sexual excitement phase. tion is limited to certain types of stimulation,
situations, or partners. For example, a man may
have an erectile difficulty when attempting sex
6.27.2.3.2 Male orgasmic disorder with a partner, but not when masturbating.
Here, the male has difficulty in reaching It is also important to note that there can be
orgasm following a normal sexual excitement comorbidity in sexual dysfunctions. The co-
phase, despite adequate stimulation. This con- occurrence of erectile dysfunction and prema-
dition has also been called ªinhibited male ture ejaculation is not uncommonly seen in
orgasm.º An earlier term, ªretarded ejacula- clinics.
tionº is problematic, as it focuses on ejaculation
rather than orgasm. In some conditions a male 6.27.3 ETIOLOGICAL FACTORS
can reach an orgasm without discharging any
semen. The new term refers specifically to the Sexual dysfunctions may be due to a variety
orgasmic experience. of etiological factors, and clinicians usually look
for organic and psychological factors. The state Further, some of the usual methods of clinical
of knowledge with regard to organic factors is assessment, such as direct observation by
not easy to summarize, as different dysfunctions therapist and reports from independent ob-
can have different etiologies. The most work has servers, are not possible for obvious reasons.
been done on male erectile disorder. Endocrine, Some of these matters, and other general issues
vascular, and neurological systems have been in the assessment of sexual dysfunction, are
seen as crucial for erectile functioning (Ban- discussed in detail in the literature (e.g.,
croft, 1997). Alcohol and other drugs of abuse, Bancroft, 1989; Hawton, 1985; Wincze & Carey,
and certain prescribed medications, can also 1991).
have a role to play. For female dysfunctions,
hormonal factors are sometimes strongly im-
plicated, as in sexual arousal disorder where 6.27.4.1 Aims of Assessment
decreases in estrogen can cause vaginal dryness. The purpose of assessment is to obtain as
Such changes are not uncommon following clear a picture as possible of the problem(s) and
menopause or ovariectomy. Local infections, factors that may be related to it, so that a good
presence of pelvic tumor, and pelvic inflamma- formulation can be arrived at. From the
tory disease are among the factors that can be perspective of psychological therapy, one would
associated with dyspareunia. Psychological want to gain information about the dysfunction
factors in the etiology of sexual dysfunctions in behavioral terms, also including relevant
have been extensively written about (e.g., cognitive aspects. What happens in the actual
Bancroft, 1989; de Silva, 1994a; Wincze & sexual situation needs to be enquired about, and
Carey, 1991). The role of anxiety, including this is usually facilitated by focusing on the most
ªperformance anxiety,º is commonly found to recent attempt. Information about the behavior
be linked to erectile disorder, and indeed some of both partners will be elicited, including their
other dysfunctions. Stresses of various kinds, antecedents and consequences. Relevant past
depressed affect, anger, and relationship factors experiences, past partners, traumatic events,
have been implicated. In women, lack of and so forth are part of the picture. A full
learning to relinquish control has been con- behavioral analysis (e.g., Kanfer & Saslow,
sidered by some authors as an important 1969) should be aimed for.
variable (McConaghy, 1993). Cognitive factors,
including attitudes and beliefs, both individual
and cultural, are also seen as relevant (e.g., 6.27.4.2 The Interview
Baker, 1993; Bhugra & de Silva, 1993; Spence,
6.27.4.2.1 Special problems
1991). The overall picture from many studies
with inconsistent results clearly points in the The main source of information in assessment
direction of multifactoral etiology for sexual is the clinical interview. In the case of sexual
dysfunctions. Biological factors, and cultural dysfunction assessment, there are special pro-
and psychological factors in the individual and blems associated with it (cf. de Silva, 1994a;
relationship domains, seem to determine the Wincze & Carey, 1991). These include the
origins of sexual dysfunctions, as indeed they following:
determine and influence sexual functioning in (i) There may be embarrassment on the part
general. These issues are well reviewed in of the patient. The therapist needs to be
McConaghy (1993) and Wincze & Carey sensitive to the difficulties the patient may have
(1991) among others. in talking about intimate matters. Starting with
more general questions may help build rapport.
Acknowledging that talking about sexual mat-
6.27.4 ASSESSMENT OF SEXUAL ters could be difficult can also help.
DYSFUNCTION (ii) The language must be simple and easy to
understand. The jargon that comes easily to a
Assessment of sexual dysfunctions should be professional is often unfamiliar to the patient.
comprehensive, and cover in detail the present- Every effort must be made to ensure that the
ing problem(s) and the relevant associated patient understands the questions.
factors. While the principles of clinical assess- (iii) Precise details need to be obtained about
ment of sexual dysfunctions is in theory no the problem presenting, going beyond general
different from the clinical assessment of other descriptions such as ªI don't seem to want it any
problems, in practice it is often a more moreº or ªI have lost interest.º The therapist,
challenging task. Since sex is a very private however, needs to be patient in enquiring about
aspect of one's life, detailed and open discussion details. Careful probing is often needed.
of it, however relevant clinically, can be difficult (iv) There should be an attitude of nonjudg-
for the patient and the inexperienced therapist. mental acceptance with regard to the patient's
Assessment of Sexual Dysfunction 607
behavior, likes, and dislikes. Even unintended detailed checklists are indeed useful, flexibility
display of disapproval or surprise may discou- is needed in their use; such a list or schedule
rage the patient from giving relevant details. should serve as a general guide rather than as
(v) It is possible that patients may not be able something to be rigidly adhered to.
to disclose some information in the initial
assessment interview. This may be due to
6.27.4.2.3 Individual and couple interviews
embarrassment, or due to the therapist being
still unfamiliar to them. It is important to allow One major issue in interviewing patients with
patients to give more information in later sexual dysfunction is whether the partnersÐ
sessions. when a couple present themselves for helpÐ
should be interviewed together or not. Different
viewpoints have been expressed about this (e.g.,
6.27.4.2.2 Areas to enquire about
Bancroft, 1989; Masters & Johnston 1970;
The areas to be covered in the interview Wincze & Carey, 1991). In general, a good
include the following: arrangement is to see the couple jointly to start
(i) The nature of the problem in as much with, and then to conduct assessment interviews
detail as required to obtain a full picture of the separately. If two therapists are available, this
difficulty and all its associated factors, includ- may be done in parallel sessions; if not, more
ing anxiety and situational variations; in men time should be spent with the partner with the
with impotence, particular enquiry should be presenting problem, followed by a briefer
made about whether early morning erections interview with the other partner.
are present or not, as their presence usually It is important that individual interview
helps to rule out the possibility that the problem sessions are undertaken in all cases. This
is organic. provides an opportunity for each partner to
(ii) The history of the problem, its beginnings give his or her version of the problem, and to
and course, and present sexual activities includ- discuss with the therapist relevant matters,
ing masturbation. including feelings about the partner, without
(iii) The partner's reactions to the problem, inhibition. It also gives an opportunity for
both in the sexual situation and in general. individuals to divulge information that might
(iv) The patient's sexual knowledge, beliefs, have been kept away from the partner, such as
and attitudes, including those determined by an extramarital relationship, or a particular
religion, culture, and subculture. aspect of the individual's past history.
(v) The patient's sexual likes, dislikes, pre-
ferences, and fantasies.
6.27.4.2.4 Motivation and selection
(vi) Past sexual history including relevant
early experiences, first experience of inter- Assessment of the motivation of the patient/
course, and so on. couple for therapy is an important aspect of the
(vii) Psychiatric and medical factors, includ- interview, although this may not prove easy in a
ing drugs, alcohol, and so forth; current depres- single interview except perhaps to identify those
sion is particularly important to assess. who are clearly unwilling to accept the treat-
(viii) Menstrual history and relation of pro- ment offered. As for suitability for therapy, an
blem to the menstrual cycle. assessment comprising two interviews at most is
(ix) Contraception and past pregnancies, usually sufficient to identify those who are
and attitude to the possibility of conception. clearly not likely to benefit from the therapy
(x) General relationship factors. that can be offered. For example, presence of
(xi) Background factors, such as job, in- clear psychiatric illness will often require
come, accommodation, extended family and appropriate treatment of that condition first;
so on, which can be sources of stress. serious marital difficulties may require referral
(xii) Previous treatment, if any. to a specialist clinic, unless therapists feel
More details may be needed on some of the competent to deal with this themselves; and,
areas than on others in a given case, and this is a when physical factors are probably involved,
matter of clinical judgment as the interview investigations of these, and a physical examina-
proceeds. Needless to say, therapists must be tion, will need to be arranged prior to
prepared to vary their enquiry to suit each acceptance for therapy.
patient, as needed. Most clinicians rely on a
history schedule or a general checklist of topics
6.27.4.2.5 Physical examination and
to enquire about as a matter of routine.
investigations
Examples of such checklists are available in,
among others, de Silva (1994a), Hawton (1985), An important issue for the clinician dealing
and Spence (1991). In practice, while such with sexual dysfunctions is that of whether or
not a physical examination and/or investiga- while Wilson (1978) has produced a useful
tions should be asked for. Nonmedical clin- fantasy questionnaire, which measures fanta-
icians cannot always assume that the clients sies, desires, and actual behaviours. The
referred to them have been adequately screened Derogatis Sexual Functioning Index (Derogatis
for possible organic factors. Some clinicians & Melisaratos, 1979) is a wide-ranging scale of
take the view that all patients presenting with sexual functioning covering 10 domains (e.g.,
sexual dysfunction should routinely be exam- information, desire, attitudes). While its com-
ined physically (e.g., Kolodny, Masters, & prehensiveness is no doubt an asset, its
Johnson, 1979; Spence, 1991). This is unneces- prohibitive length (245 items) makes it some-
sary, but it is essential to have the facilities to get what unwieldy for routine clinical use. A brief
this and relevant investigations done if required measure for assessing erectile functioning,
in a given case. Bancroft (1989) has given an developed recently, is the International Index
extremely useful set of indications for physical of Erectile Function (Rosen et al., 1997).
examination. These are: A relatively recent British development is the
(i) complaints of pain or discomfort during Golombok±Rust Inventory of Sexual Satisfac-
sex; tion (GRISS; Rust & Golombok, 1986). This
(ii) recent history of ill-health or physical 28-item questionnaire, intended for use with
symptoms other than the sexual problem; heterosexual couples or individuals with a
(iii) recent onset of loss of sex drive with no current heterosexual relationship, yields an
apparent cause; overall score, for men and women separately,
(iv) when the patient believes that a physical of the quality of sexual functioning. In
cause is most likely, or is concerned about the addition, the following subscores can also be
genitalia (e.g., a man complaining that his penis obtained: erectile dysfunction, premature eja-
is too small or bent, or a woman suspecting that culation, anorgasmia, vaginismus, infrequency,
there is something abnormal about her sexual poor communication, dissatisfaction, nonsen-
organs); suality, and avoidance. This instrument has
(v) history of abnormal puberty or other good reliability, and is easy to use. In view of
endocrine disorder; the multiplicity of scores it yields, the GRISS is
(vi) in men, being aged over 50; and an economical instrument that can be used
(vii) in women, being in the pre- or post- routinely.
menopausal age group or having a history of A parallel, and equally economical, instru-
marked menstrual irregularities or infertility. ment for the assessment of the quality of the
Where appropriate, the medical practitioner overall relationship is the Golombok±Rust
carrying out the physical examination will also Inventory of Marital State (GRIMS; Rust,
carry out, or arrange for, relevant laboratory Bennun, Crowe, & Golombok, 1988). Other
investigations. Details of the common investi- established marital questionnaires include the
gations may be found in several sources includ- Locke±Wallace Marital Adjustment Scale
ing Bancroft (1989), Hawton (1985), and (Locke & Wallace, 1959) and the Dyadic
Wincze & Carey (1991). Adjustment Scale (Spanier, 1976). The recently
developed Marriage and Relationship Ques-
tionnaire (Russell & Wells, 1993) is another
6.27.4.2.6 Questionnaires and inventories
useful instrument to be considered.
Data obtained from the interview can profit- When depression is a relevant factor needing
ably be supplemented by the use of question- to be assessed, a standard depression inventory
naires and inventories. These help to cover some may be used for this purpose. The same applies
important areas quickly, but more importantly to anxiety.
they provide quantitative data that are parti-
cularly useful in assessing differences between
6.27.4.2.7 Subjective ratings
before and after treatment.
Several useful instruments are available for Self-rating scales may be used as part of an
the measurement of sexual experiences, atti- assessment of the major variables in question for
tudes, dysfunctions, and other related matters. a given patient. For example, anxiety in sex,
Hoon, Wincze, and Hoon (1976a) provide an desire, and sexual arousal may each be rated by
inventory (Sexual Arousability Index) for the the patient on a 0 to 100 scale indicating
assessment of female sexual arousal. Lo Piccolo subjective estimates (cf. de Silva, 1994a).
and Steger (1974) have developed an inventory Patients usually find these simple scales easy
(Sexual Interaction Inventory) to assess sexual to use. Equally simple are frequency charts,
interaction and satisfaction of a couple. Lief and recording the frequency of target behaviors on a
Reed (1972) provide a questionnaire to assess daily basis. A predesigned diary provided by the
both sexual knowledge and sexual attitudes, assessor/therapist, specifying the targets to be
Treatment of Sexual Dysfunction 609
recorded, is an effective way of obtaining reavement, discovery of partner's adultery,

baseline data as well as of monitoring change. failure while attempting sex in insecure circum-
Conte (1986) and Spence (1991), among others, stances);
provide discussions of these. (iv) perpetuating factors (e.g., anxiety about
possible failure, ongoing marital conflict, con-
tinuing stress at work); and
6.27.4.2.8 Physiological measures (v) prognostic factors (e.g., good overall
Physiological techniques have been used in relationship and commitment of both to the
the assessment of sexual function for many marriage as good prognostic factors).
years, receiving impetus from the work of The formulation will provide a tentative
Masters and Johnson (1966, 1970). Measuring explanation of the problem, and also establish
techniques are available for both male and a basis for treatment. The formulation is fed
female arousal. Penile plethysmography for the back to the patient or couple, and discussed.
assessment of erection is widely used in research Revision of the formulation may follow this
and can be used in clinical practice where needed discussion.
and practicable (e.g., Wagner & Green, 1981;
Wincze et al., 1988). The measure may be of
either penile volume or penile circumference 6.27.6 TREATMENT OF SEXUAL
changes. Penile plethysmography has also been DYSFUNCTION
used to assess nocturnal erections in an attempt 6.27.6.1 Behavioral Sex Therapy
to distinguish psychogenic from organically
caused impotence (Karacan, 1978). The injec- 6.27.6.1.1 The behavioral approach
tion of a chemical vasodilator, such as papa-
verine, into one of the corpora cavernosa of the Historically, there have been several psycho-
penis, is also used in the assessment of erectile logical approaches to sexual problems (de Silva,
disorder. If the patient develops a full erection 1994b). However, the major approach since the
following the injection, severe vascular insuffi- 1960s has been the behavioral one. Behavioral
ciency can be excluded as a cause of the sex therapy became established as the treatment
problems (Brindley, 1983; Wagner, 1993). As of choice for these problems in the 1970s, and
for female arousal, the best established method began to be practiced widely in various parts of
is the photoplethysmography technique (Hoon, the world (Gillan, 1987).
Wincze, & Hoon, 1976b), in which vasoconges- In the modern folklore of sex therapy, it is
tion in the vaginal walls is measured with the widely held that the basic techniques of
help of a probe. Detailed discussions of these, behavioral sex therapy derive from the work
and other laboratory techniques, for the of William Masters and Virginia Johnson
assessment of sexual problems are provided (Masters & Johnson, 1970). It is certainly true
by Bancroft (1989), Meisler and Carey (1990), that Masters and Johnson developed, estab-
McConaghy (1993), and Schiavi (1992). lished, and popularized a treatment package
In a clinical setting, however, the use of that has had a major impact. However, the roots
physiological methods for routine assessment is of behavioral sex therapy can be traced to the
not feasible. Also, the interpretation of their work of Joseph Wolpe in South Africa. Wolpe is
results in the clinical context is not always clear- regarded as the pioneer of modern behavior
cut (Bancroft, 1989; Conte, 1986). therapy, his work from the late 1940s on the
application of learning principles to the analysis
and modification of behavioral problems cul-
6.27.5 FORMULATION minating in his book Psychotherapy by recipro-
cal inhibition (Wolpe, 1958). While much of the
All the information gained from the different work reported in this book related to phobias
aspects of assessment need to be carefully and other anxiety disorders, Wolpe also
integrated. This should lead to a case formula- reported behavioral work on sexual dysfunc-
tion, the equivalent of a working hypothesis tions. He recognized the crucial role of anxiety
(Carey, Flasher, Maisto, & Turkat, 1984; in sexual problems, and used anxiety reduction
Hawton, 1985). A good formulation will include as a key element in the treatment of these
the following: problems. The principle of the couple under-
(i) a detailed description of the problem; taking cooperative therapy, the need to remove
(ii) predisposing factors (e.g., cultural be- pressure to perform, and the use of a graded
liefs, history of diabetes, strict upbringing, series of activities eventually leading up to the
childhood traumatic events); resumption of sexual intercourse, which are
(iii) precipitating or triggering factors (e.g., seen as three major elements of present-day sex
childbirth, physical illness, redundancy, be- therapy, were key aspects of Wolpe's approach.
Wolpe (1958) cites cases of both erectile Schmidt, 1983; Bancroft, 1989; Crowe, Gillan,
dysfunction and premature ejaculation with & Golombok, 1982).
whom he had successfully used this approach. It The main elements of the conjoint cognitive-
is perhaps worth quoting a passage that behavioral sex therapy approach may be
summarizes Wolpe's approach: summarized as follows:
(i) Treating the dysfunction as a joint pro-
The patient is told to inform his sexual partner blem. This helps to reduce worry and guilt in the
(quoting the therapist if necessary) that his sexual presenting partner and also emphasizes that the
difficulties are due to absurd but automatic fears in need is to learn, or relearn, how to have
the sexual situation, and that he will overcome satisfactory sex jointly.
them if she will help him, i.e. if she will participate (ii) Reduction of anxiety. This is achieved by
on a few occasions in situations of great sexual several strategies, including banning any at-
closeness without expecting intercourse or exerting
tempt at intercourse. This removes the pressure
pressure toward it. He is to ask her to be patient
and affectionate and not to criticize. Assured of to perform. Relaxation training may also be
her cooperation, he is to lie in bed with her in the used as an extra help. Graded steps are recom-
nude in a perfectly easy, relaxed way, and there- mended, so that progress is achieved without a
after to do just what he really feels like doing and resurgence of anxiety.
no more. He has no duty at any stage to reach any (iii) Setting sexual tasks or assignments to be
criterion of performance. It is found that from one carried out at home. They are specific beha-
love session to the next there is a decrease in vioral tasks and involve touching, caressing,
anxiety and an increase in sexual excitation and and so on. The two main stages of this are
therefore in the extent of the caresses to which the ªnongenital sensate focus,º where the touching
patient feels impelled. He has increasingly strong
excludes genitals and breasts, and ªgenital
erections, and usually after a few sessions coitus is
accomplished and then gradually improves. sensate focusº where these are included. These
(Wolpe, 1958, p. 131) basic tasks aim to help the couple to learn giving
and receiving pleasure by touch, with no
pressure for performance, moving from less
sexual to more intimate interactions.
6.27.6.1.2 Present-day conjoint cognitive-
(iv) Work on eliciting and changing negative
behavioral sex therapy
or problematic cognitions.
While the work of Wolpe (1958) represents (v) Educating the couple in sexual knowl-
the early use of standard behavior therapy edge, for example, anatomy, physiology, coital
techniques for sexual dysfunctions (see also positions.
Lazarus, 1963), it is profitable to consider these (vi) Helping the couple to develop sexual and
and other behavioral techniques as elements other communication skills.
that may be incorporated into a wider treatment (vii) Using specific additional techniques for
package. The obvious reason for this is that specific dysfunctions.
sexual problems are often multifaceted so that While (i) to (vi) above are common to all,
to deal with them effectively one needs several there are specific interventions designed to deal
methods. The general package most widely used with specific presenting problems. The timing of
in this way is the conjoint therapy of Masters their introduction is flexible; they are usually
and Johnson (1970), modified and further introduced after some progress has been made
developed by subsequent writers (e.g. Bancroft, in the common stages.
1989; Gillan, 1987; Hawton, 1985; Spence, 1991; This program is a cognitive-behavioral pack-
Wincze & Carey, 1991). One major new age in that there is no attempt to interpret the
development is the incorporation of cognitive presenting symptoms in terms of psychody-
principles and techniques (e.g. Baker, 1993; namic constructs, and that behavioral tasks and
Spence, 1991). This approach may be termed cognitive work are a major part of the package.
ªconjoint cognitive-behavioral sex therapy.º The degree to which an approach geared
In the Masters and Johnson conjoint therapy towards unraveling conflicts and problems in
approach, the presenting partner and spouse are the overall relationship is incorporated into this,
seen as a couple for therapy. In the original varies from therapist to therapist and from case
program, each couple was seen by a male and to case (Beck, 1992; Crowe & Ridley, 1990;
female cotherapist team. Therapy was carried Woody, 1992). Anxiety reduction is a key part
out on an intensive basis: daily sessions over a of this package. The prohibition of attempts at
two-week period (Masters & Johnson, 1970). intercourse helps to achieve this, as immediately
Other clinicians and researchers found that the the performance anxiety in the male and fears of
involvement of a second therapist added little to pain and so on in the female are removed. Other
the program and that sessions did not need to be techniques of anxiety reduction may be added as
so closely massed together (Arentewicz & required. McCarthy (1977, 1992), for example,
has listed a number of ways, both general and if I continue to lose my erectionsº or ªI can't be
specific, in which anxiety can be reduced in very masculine if I don't last long with a
sexual problems. partner.º Baker (1993) argues that these
The sensate focus assignments help a couple negative thoughts play a crucial role in main-
to learn to relax in each other's company and taining, and in some cases even causing, sexual
enjoy physical contact and interaction without dysfunctions. The cognitive approach she uses
worries of failure. In this relaxed, mutually aims to challenge and modify these dysfunc-
pleasuring stage, they can acquire the con- tional cognitions, and to break the vicious circle
fidence to move towards more intimate inter- of negative thoughts that contribute to diffi-
actions. It is perhaps worth noting here that the culties. The role of cognitive work has also been
progression from nongenital to genital sensate emphasized by Bancroft (1997) and Wincze and
focus, and from there to more specific and more Carey (1991). The need to focus on the partner's
explicitly sexual acts, is similar in many ways to cognitions as well as those of the presenting
an in vivo desensitization program (Wolpe, patient has also to be emphasized. Typical
1958). Self-exploration may also be incorpo- partner cognitions include: ªI am no longer
rated into the program where required. Com- exciting to him,º ªHe is just not trying,º and
munication, both verbal and nonverbal, on ªShe must be having an affair with someoneº
matters of pleasure, sensations, and sexual (cf. Wincze & Carey, 1991).
responses is encouraged and taught (e.g., how Specific techniques are incorporated into this
to indicate to the partner where and how to general program in the treatment of specific
touch and how to express pleasure at what the disorders. Comments on the treatment of some
partner is doing). The verbal aspects of this kind specific dysfunctions are made below.
of simple, but to many couples new, interaction
may be role-played and rehearsed during
(i) Hypoactive sexual desire disorder
therapy sessions. The meetings with the thera-
pist are crucial in discussing progress or Low interest usually begins to respond to the
otherwise of the homework assignments, and general treatment package if nothing more
difficulties and problems are discussed fully. serious is underlying. Additional techniques are
Not infrequently in these feedback discussions self-focusing, self-stimulation, use of vibrators,
relevant new material about the relationship and stimulation with erotic material such as
emerges for the first time (Bancroft, 1989; pictures, videos, and audiotapes. (Gillan, 1979,
Hawton, 1985). 1987). It is important, however, that the kind of
Cognitive therapy principles have a key part erotic material recommended or provided is not
to play. The elicitation and modification of distasteful to the patients, and so the choice is
cognitions related to the dysfunction are the best left to them. Fantasy training is a related
main feature of this, and individual work along technique, sometimes useful for those whose
these lines is often a key part of therapy. Where fantasies are minimal (Spence, 1991). To
maladaptive cognitions have a role in the encourage fantasies, published fantasy materi-
genesis and/or maintenance of a problem, these als may be used, such as the volumes of fantasies
need to be challenged and changed. Common published by Nancy Friday (1976, 1991).
myths, attitudes, and idiosyncratic beliefs, and Masturbation training, usually with fantasy,
so forth, often contribute to sexual difficulties may also be considered. The use of agreed
(Baker & de Silva, 1988; Bishay, 1988; de Silva timetables for sex are also found to be useful
& Dissanayake, 1989). Spence (1991) has (e.g., Crowe & Ridley, 1990). The therapist
provided a useful discussion of the use of would negotiate with the couple a timetable for
cognitive strategies in the treatment of sexual sex; for example, intercourse will take place only
difficulties. She includes fantasy training and on certain days of the week, or sex will be
attention-focusing skills as possible aspects of initiated by each partner on certain days only.
therapy. The major cognitive interventions, This approach is often quite effective in cases
however, consist of identifying and restructur- where the partner with the low level of desire
ing the relevant cognitions. Maladaptive or finds the demands made by the spouse too
negative thoughts need to be identified and much, thus making the problem worse. The
changed as needed (Zilbergeld, 1978, 1992). timetable helps to establish an acceptable
This approach is well represented in the work of pattern or schedule, within which further
Baker (1993). She highlights the role of the progress can be made.
individual's core assumptions about gender role
and accompanying expected behaviors. Such
(ii) Male erectile disorder
assumptions are reflected in automatic
thoughts, commonly reported by patients in In the genital sensate focus stage, ªteasingº is
sex therapy, such as: ªMy partner will leave me introduced, that is, periods of penile stimulation
alternating with absence of stimulation. While elements may need to be added to the program.
erections may spontaneously occur, these are For example, orgasmic reconditioning may be
not considered the aim of therapy at this stage attempted, in which the patient is taught to pair
and the couple are encouraged to let the erection the positive pleasurable aspects of self-stimula-
subside before restimulating. This helps in tion or other sexual situations with images of the
training them not to rush to intercourse once partner in a fantasy-based graded program
an erection is there, and also demonstrates that (Asirdas & Beech, 1975; Gillan, 1987).
erections, when lost, can reappear. The next In some, perhaps many, instances a woman's
stage is vaginal entry, in the female superior inability or difficulty in reaching an orgasm is
position but with no movement. In the following linked to her inability to relinquish control
stage the female makes slow movements, (McConaghy, 1993, 1996). Some help specifi-
eventually leading to the male participating in cally directed towards this, involving education,
and/or initiating movement, and using different counseling and practice exercises, is necessary in
positions. such cases.
Cognitive work has a particularly valuable
role to play in the treatment of this disorder.
(iv) Male orgasmic disorder
Positive sexual thoughts should be identified
and encouraged. The patient needs to be helped The aim is to work towards intravaginal
to refocus his thinking onto more positive ejaculation, in a series of steps gradually
cognitions. One way of doing this is to approaching this goal. Again the instructions
encourage recall of the thought content during are introduced at the genital touching stage. For
past satisfactory sexual experiences. The thera- those males who do not reach an orgasm easily
pist can also help the patient to develop positive in any situation, vigorous stimulation (ªsuper-
thoughts by prompting ªtypicalº helpful stimulationº) with the aid of a lubricant is
thoughts (Wincze & Carey, 1991). There is also recommended. The use of a vibrator may also be
a need to appraise and reappraise the meaning considered. Once orgasm can be achieved in this
of specific types of sexual acts. Negative way, vaginal entry, after some initial manual
meanings or appraisals that inhibit the sexual stimulation, may be attempted. In those men
functioning need to be altered (cf. Bancroft, whose problem is that they cannot reach orgasm
1997). in the vagina but can do so with manual
Some cognitive work may also be needed with stimulation, a graded program in which orgasm
the partner. Partners of men with erectile is achieved by manual stimulation, with the
disorder not uncommonly develop negative penis increasingly close to the vagina, is
cognitions, and they need to be dealt with. recommended. In the next stage vaginal entry
is achieved, after stimulation by hand close to
orgasm. Even then, some manual stimulation
(iii) Female orgasmic disorder
may be needed to achieve orgasm once the penis
For females with orgasmic dysfunction the is in the vagina. Suitable coital positions that
main additional element in the therapy package facilitate these steps need to be recommended.
is a good deal of self-focusing and self- Subsequently, vaginal stimulation alone will be
stimulation (Barbach, 1980; Gillan, 1987; Hei- sufficient for orgasm (Kaplan, 1987).
man & Lo Piccolo, 1988; Lo Piccolo & Stock,
1986). This helps the patient to learn to enjoy the
(v) Premature ejaculation
sexual sensations in a relaxed manner. These
self-sessions, including stimulation until orgasm There are two, closely similar, techniques
is achieved, can be built into the basic program used for premature ejaculation. Masters and
as parallel assignments. It has been shown that Johnson (1970) recommend what is called the
the use of vibrators can help these women to ªsqueezeº technique. The couple are asked to
achieve orgasm; this may be done by the patient practice this in the genital touching state. The
herself first, and the partner may help her to female stimulates the penis of her partner with
achieve orgasm with the vibrator in later stages. her hand, and when the man feels he is about to
The use of fantasy and erotic materials may also reach a climax, he indicates this to her with a
be used as an adjunct (Gillan, 1979, 1987; prearranged signal. She then squeezes the penis
Spence, 1991). Exercises to achieve control over hard for two or three seconds. For squeezing,
the pubococcygeal muscle and to strengthen its the penis is held with the thumb on the frenulum
tone, commonly referred to as ªKegel exercisesº and the first and second fingers on the opposite
(Kegel, 1952), have also been recommended as surface, one on each side of the coronal ridge.
an aid to achieving orgasm. For females who are The squeeze makes the man lose his urge to
unable to achieve orgasm with the partner but ejaculate, and also perhaps some of the erection.
have no problem in masturbation, other This process of stimulation and squeeze is
repeated several times in a session. Several have a flexible approach in applying the therapy
sessions of this leads to gradual increase in package or parts of it.
ejaculatory control, and the couple is then asked
to effect vaginal entry, in the woman-above
(ii) Psychogenic and organic problems
position. At first, entry is not followed by
movement. If the man feels he is about to The program is intended mainly for psycho-
ejaculate during vaginal containment, he com- genic problems, as patients with clearly organic
municates this to his partner who then lifts problems may need different forms of therapy.
herself off him lightly and applies the squeeze. On the other hand, there is no reason why some
Kolodny et al. (1979) recommend a basilar aspects of the program should not be used even
squeeze technique at this stage so that the penis with those whose problems are not psychogenic,
does not have to be completely disengaged. The as a way of helping them to relax in their sexual
penis is held at the base, anterior to posterior, activity and enhance their sexual experience,
and the pressure applied. The couple may thus facilitating whatever physical treatment
eventually revert to preferred positions. may be used. For example, in elderly men with
The squeeze technique is, in fact, a variant of erectile dysfunction who, due to aging and other
the start±stop method described in 1956 by physical causes, may not be able to have erectile
Semans, which is used by many therapists (e.g. function restored, much can still be achieved by
Kaplan, 1974). This consists of stimulating the a program aimed at enhancing their enjoyment
penis and stopping at the point of near-climax, of sexual activity, enabling them to accept that
and repeating the process several times. Initi- sex need not always mean vaginal intercourse
ally, the stimulation is with a dry hand; later a (Gibson, 1992). It is also important to remem-
lubricant is used to increase sensitivity and ber that the psychogenic±organic distinction is
make the sensations more like the experience of not always clear cut, and there are often
vaginal entry (Gillan, 1987). The rest of the multiple causal factors (Bhugra & Crowe,
program consists of vaginal containment with- 1995). A problem caused, or triggered, by a
out movement, followed by movement in the physical condition, may often be aggravated or
woman-above position. maintained by psychological factors, such as
anxiety, invalidism, and diminished self-esteem.
In many cases, substantial psychological help is
(vi) Vaginismus
needed in addition to a physical intervention.
This is treated by helping the patient, as a first
step, to learn to relax and to explore her own
(iii) Flexibility
genitals. Following this, a graded series of steps
involving penetration using own fingers, and The program is meant to be applied flexibly.
dilators (or trainers) of increasing sizes, is The needs of each couple determine what
undertaken (Gillan, 1987; Scholl, 1988). The use changes to aim for, and the therapist must be
of a vaginal lubricant may be advised. After the prepared to change the direction of a program
initial stages, the partner may be included in the as and when required; for example, a couple
procedure. This is done, however, with the presenting with a premature ejaculation pro-
patient retaining control. In many cases, this blem may turn out to be one where the basic
graduated dilation training leads to quick problem is lack of responsiveness in the female.
improvement. Some couples require a good deal of direct
education; shy patients may not be able to
participate fully in therapy sessions until their
6.27.6.1.3 Some general considerations on
embarrassment is overcome, and will need
therapy
considerable time and effort to reach the point
Some general points about this treatment where therapy can proceed. The need for
approach need to be made. flexibility is very well illustrated by Lobitz,
Lo Piccolo, Lobitz, and Brockway (1976) and
Wincze and Carey (1991).
(i) The therapy package
The package in its basic form is for use with
(iv) Resistance to the program
all sexual dysfunctions, with the specific
elements added to suit specific difficulties. The program can sometimes meet with
There are, however, many instances where there resistance. A couple may not carry out home-
is no need to apply the whole package, where work assignments, or do them only infrequently
perhaps sexual counseling and basic education or cursorily. Their difficulties will need to be
are all that is needed (Bancroft, 1989; Hawton, fully explored. Previously unacknowledged
1985; Kaplan, 1987). The therapist needs to marital or relationship problems may come to
the surface at this stage, in which case efforts 6.27.6.3 Therapy for Those Without Partners
should be directed towards resolving these
(Bancroft, 1989; Crowe & Ridley, 1990). When a patient comes for therapy without a
partner, what help can be offered? If the patient
has a steady partner who, though unwilling to
(v) Additions to the program come to the clinic, will co-operate with a therapy
Additions to the basic program need not be program, a ªremote controlº approach may be
confined to the specific techniques mentioned used, with the presenting partner also acting as
above. Any suitable cognitive and/or behavioral communicator of instructions. The use of
technique for aspects of the problem may be written material will be particularly useful in
incorporated as required. For example, when a such cases. Clinical experience shows that this is
strong phobic element is present, an interven- a less than ideal substitute for conjoint therapy,
tion to deal with the phobia may be used; for a but should be considered in the right circum-
man whose dysfunction is bound up with stances. If the refusal of the partner to attend the
paraphiliac desires, a parallel program aimed clinic reflects a poor relationship, and/or an
at dealing with these may be required (de Silva, attitude that it is all the other's problem, then
1995). clearly the chances of joint work being success-
fully carried out are slim.
A somewhat different problem arises when
(vi) Functional analysis the patient has no partner available. Many
young men with erectile or ejaculatory problems
The notion of functional analysis (Kanfer & not only do not have a steady partner but also
Saslow, 1969) is extremely useful in devising avoid developing relationships, through fear of
individualized treatment programs. When the failure and rejection. Individual therapy is the
assessment shows clearly identifiable factors only option available in such cases, unless group
related to the problem behavior, the systematic therapy is considered and facilities are available
manipulation of these can achieve impressive for it (see below).
results, usually as part of the program, but The basic principles of individual sex therapy
sometimes also as the main intervention (Lobitz are largely the same as those for couples.
et al. 1976). Education, counseling, anxiety reduction in
various ways including relaxation, self-focusing
6.27.6.2 Some Practical Issues and self-stimulation, and fantasy training are all
possible and useful elements in such programs.
As noted earlier, Masters and Johnson (1970) Cognitive principles have a key role. As for
used male and female teams of cotherapists in specific techniques, premature ejaculators will
their program, but others have shown that a find the start-stop technique easier to use than
second therapist adds little to the program the squeeze. Imaginal desensitization may be
effectiveness (e.g., Crowe et al., 1982). On the used for fear or anxiety, while role play and
other hand, in certain cases an additional social skills training can be useful where
therapist of the opposite sex to the main required (McCarthy, 1992). The sexual re-
therapist can be an advantage, for example, education program of Zilbergeld considers it
by making it easier for both of the partners to important to dispel some widespread male
communicate about the problem and their ªmythsº about sex (such as that sex always
feelings about it. means intercourse, that the male must always
The individuals should be given an opportu- take the active role, and so on) in helping these
nity to report to the therapist separately, that is, persons, and explorationÐand correctionÐof
in the absence of the partner, at least in some of the individual's misconceptions about sex will
the sessions. This enables the therapist to gain a be a useful element in an individual sex therapy
balanced account of the progress and related program (Zilbergeld, 1978, 1992). For females,
matters. masturbatory exercises, Kegel exercises, fantasy
Giving written instructions, with illustra- training, vibrator use, and other such techniques
tions, is a valuable addition to the therapy that are possible for the individual to use
program. They should be used as a supplement without a partner, may be used as needed.
to verbal instructions. Equally useful is to The treatment of individuals without partners
recommend a well-written basic book on sex. presenting with sexual problems is discussed by,
There are many good books that may be among others, Anson (1995) and Catalan,
recommended, for example, Barnes and Rod- Hawton, and Day (1991).
well (1992), Delvin (1974) and Yaffe and The use of surrogate partners in the treatment
Fenwick (1986a, 1986b). Films, videos, and of patients who come without partners has been
slides may also be used (Gillan, 1987). reported and recommended by some therapists.
Several sex therapists in the USA use surrogate and failures, and so on (Beck, 1992). Within
therapy (Dauw, 1988; Sommers, 1980), while in these limitations, the available data are en-
the UK Cole (1988) has described such therapy couraging. There are no reliable comparative
with 425 patients, 390 men and the rest women. outcome data, but on the whole 50±60% of
Of these, 316 (74.4%) completed therapy; couples who enter treatment show satisfactory
unfortunately, the follow-up was possible in outcome. Marked differences in outcome exist
only 13.3% of these. There are serious problems for specific sexual dysfunctions. For example,
with the use of surrogate therapy, including excellent results are obtained for vaginismus
obvious legal and ethical issues. For example, in (e.g., Hawton & Catalan, 1990), whereas the
the Cole sample, the spouse in many cases was treatment of hypoactive sexual desire appears to
not aware that the patient had come for be less effective, especially in the long term (e.g.,
therapy. A serious clinical question is whether Hawton, Catalan, & Fagg, 1991). While the
patients who have been treated with a surrogate conjoint cognitive-behavioral therapy approach
partner will be able to generalize their gains to is the best option when it is feasible, it is up to
other situations. In view of these reservations, it clinicians to use their ingenuity and judgment in
is difficult to recommend surrogate therapy as choosing, for each case, those elements of
an option in the management of sexual therapy that are particularly suitable for the
dysfunction. problems they are called upon to deal with.
A related issue is that of the mechanisms of
change. Even when various techniques and
6.27.6.4 Group Therapy strategies achieve clinical success, the mechan-
isms through which change has been achieved is
In recent years, an increasing number of
not always clear. Bancroft (1997) has recently
therapists have treated patients with sexual
highlighted this issue and offered a valuable, if
dysfunction in groups. There are reports in the
brief, discussion. The relative lack of under-
literature of male groups, female groups, couple
standing of mechanisms of change also reflects
groups, and mixed-single groups; and there
the uncertainty about the etiological factors in
have been groups for patients with similar
these dysfunctions.
problems and groups for heterogeneous pro-
The outcome literature also points to factors
blems (e.g., Barbach & Flaherty, 1980; Kayata
associated with prognosis. Good prognostic
& Szydlo, 1988; O'Gorman, 1978; Spence, 1985;
factors include the quality of the overall
Zilbergeld, 1975). The groups have used a
relationship. Motivation for therapy also
variety of techniques, including education, task-
appears to be a key factor. There is also some
setting, relaxation, desensitization, instructions
evidence that the attractiveness of the partners
to use masturbation and vibrators, and open
to each other predicts satisfactory outcome.
discussion of problems. Particularly for young
Current psychiatric illness is a predictor of poor
and sexually diffident persons, the experience of
outcome. These issues have been reviewed by
well-conducted group therapy can be of much
Hawton (1992).
benefit (Bancroft, 1989).
6.27.6.5 Efficacy of Therapy 6.27.6.6 A Note on Physical Treatments

What about the efficacy of the therapeutic A brief note is necessary about physical
approaches and techniques that have been treatment. A variety of physical interventions
discussed above? The very high success rates are used in medical settings for sexual dysfunc-
reported by Masters and Johnson (1970; also tions. It is beyond the scope of this chapter to
Kolodny et al., 1979) have not been matched by review these. Hormonal therapy, surgery,
later investigators but there is, generally, vacuum devices, and penile prosthetic devices
evidence that the conjoint cognitive-behavioral have been used, and certain drugs have also
approach is beneficial to many patients (Are- been claimed to be of value. Much of this work
ntewicz & Schmidt, 1983; Bancroft, 1989; has been reviewed by Bancroft (1989), Bhugra
Hawton, 1992; Hawton, Catalan, Martin, & and Crowe (1995), McConaghy (1996) and
Fagg, 1986; Spence, 1991). A thorough evalua- others. In recent years, many reports have
tion of sex therapy outcome is not easy to appeared on the use of injections of smooth
undertake because of various confounding muscle relaxants such as papaverine and
factors: heterogeneity of samples, lack of prostaglandin E into one of the corpora
uniformity in outcome measures, ambiguity cavernosa of the penis to induce erections
of criteria of improvement, preponderance of (e.g. Brindley, 1986; Linet & Ogring, 1996). The
single-case reports, poor description of patient erections induced in this way may last from one
characteristics, absence of data on drop-outs to four hours and are usually adequate for
satisfactory intercourse. The patient is taught to looked into; for example, ªthe financial success
give these injections himself, and the partner that comes to a man who works especially hard
may also be taught to play this role. The use of to compensate for his erectile failureº (Lo
this method to help men with organically caused Piccolo, 1994, p. 6).
erectile problems, or those who have failed to It is clear that all but one of these aspects of
respond to an adequate trial of psychological sexual dysfunction highlighted by Lo Piccolo
methods, is advocated by several authorities. (1994) can be accommodated easily within the
There is, however, an urgent need for further broad framework of the cognitive-behavioral
research and the use of this approach needs approach. In fact this happens almost routinely
caution (Althof & Turner, 1992; Bhughra & in actual clinical practice. As noted above,
Crowe, 1995; Crowe & Qureshi, 1991). The relationship factors are always an important
procedure also has some side-effects, especially area to investigate and work on in sex therapy.
parapism (prolonged erection) in a small A systemic approach may be of much value in
number of cases. An even more recent devel- this endeavor in some cases. Such an approach
opment is the intraurethral administration of can be accommodated easily within a broad
prostaglandin E (e.g., Wolfson, Pickett, Scott, cognitive-behavioral framework, as demon-
De Kernion, & Rajfer, 1993). strated by Crowe and Ridley (1990). The
When used appropriately after careful in- reinforcing value of the sexual problem would
vestigation, physical methods do have a useful naturally be investigated and dealt with in the
role in the treatment of sexual dysfunctions. cognitive-behavioral approach, as indeed it is
However, when the problem is largely psycho- done for all behavioral difficulties (Kanfer &
logically determined, the use of physical treat- Saslow, 1969). The historical aspects of a case
ments can be counterproductive. Even when need to be considered in any approach, and a
there are physical causes of the presenting good cognitive-behavioral formulation would
problem, and the main treatment is of a physical necessarily include recognition of these.
nature, additional psychological help along the As for the psychodynamic value and sig-
lines discussed above is often useful and nificance of a symptom, this may appear at first
necessary (Wincze & Carey, 1991). The reliance sight to be an aspect that does not easily fit
on a physical treatment alone in the treatment of within a cognitive-behavioral framework. Ka-
sexual dysfunction is not recommended (Bhugra plan (1974, 1987) has argued for the use of a
& Crowe, 1995). psychodynamic approach if and when beha-
vioral procedures produce no further change in
6.27.6.7 Scope of Cognitive-behavioral Sex a patient, in other words when there is
Therapy resistance. However, it can be argued that a
broadly conceived cognitive-behavioral ap-
It was noted above that success rates have proach, imaginatively applied, should be able
declined in recent years when compared to the to deal with these matters. It appears that what
very high rates reported in early years. This may is needed in such cases is for the individual to be
be due to changes in culture and to changes in helped to reappraise the meanings of certain
the nature of referrals for specialist help. Lo sexual acts or responses (Bancroft, 1997).
Piccolo (1994) has argued that the behavioral Negative meanings acquired in childhood,
approach of the 1970s and the 1980s needs to be persisting into adult life and inhibiting appro-
augmented, and that a ªpostmodernº sex priate sexual responses, need to be reappraised.
therapy is required. In this approach, while As Bancroft (1997) points out, there is no doubt
the behavioral outlook is still the primary that this endeavor ªlends itself particularly well
feature, the role that sexual dysfunctions may to the cognitive-behavioral approachº (p. 247).
play in maintaining a systemic homeostasis for What is required is for the therapist to lead the
the couple in crucial areas of their relationship patient towards this necessary reappraisal with
(e.g., intimacy, trust, power) is recognized, and the skillful and sensitive use of cognitive-
is appropriately dealt with. Second, it is behavioral principles.
recognized that a sexual problem may have
individual psychodynamic significance. Third, 6.27.7 TREATMENT ISSUES WITH
it is recognized that a sexual dysfunction may be SPECIAL POPULATIONS
a mechanism for the patient to deal with
unresolved family or origin issues, such as Sexual dysfunctions occurring in various
problems of closeness associated with an special populations need some consideration.
alcoholic father, or an aversive reaction asso- The approach to treatment described in the
ciated with incestuous abuse. Finally, the above sections is a robust one, the principles of
operant reinforcing value of a sexual dysfunc- which are applicable to all groups. However,
tion for clients in their larger environment is certain additional considerations are sometimes
Treatment Issues with Special Populations 617
needed, and treatment needs to be adapted as then be providing information about the
required. A few commonly encountered special common changes in sexual functioning with
clinical populations are discussed below. increasing age, thus allaying any undue anxiety.
The variability of the effects of aging on sex
6.27.7.1 The Elderly needs to be emphasized. Further, increasing the
need for direct physical stimulation of the
Elderly couples and individuals increasingly partner's penis in order to obtain an erection has
attend services for sexual problems (Gibson, to be emphasized, and the instructions for
1992; Spence, 1991). This is not because of any touching and foreplay need to include this as a
real increase of sexual dysfunctions in the group, major part.
but because of the awareness of the availability
of services and also the increasing acceptance 6.27.7.2 Those with Physical Handicaps and
that sexual activity in later life is not something Chronic Illnesses
to be ashamed of (Gibson, 1992). Erectile
disorder is one of the commonest presentations Many clients with physical handicaps and
(Mulligan, 1989); male and female orgasmic chronic illnesses seek help for sexual problems.
disorder also present for help. While physiolo- Cardiac problems, epilepsy, arthritis, cancer,
gical influences have a clear role to play in some and prostrate problems are among the difficul-
of these cases, problems of ill-health can also ties that are commonly encountered. Assess-
contribute to, and/or complicate, the difficulties. ment should include full details of the problems,
Changing life circumstances, including the including the study of medical reports about the
nature of the overall relationship between a client's difficulties. The medication the client
couple, are also relevant factors. Psychological may be on is also important to ascertain, as it
factors, especially attitudinal ones, may also may well have an effect on sexual functioning
play a part. It is not uncommon for elderly and the presenting dysfunction may even be just
people to take the view that sexual activity a secondary result of medication. A third area to
should no longer be part of their lives, and this pay attention to is how the physical illness or
can be a problem when the partner continues to handicap has affected the person psychologi-
desire an active sex life. cally, mainly in the areas of self-image and role
In the treatment of elderly clients, all of the in relation to the partner. Chronic illness and
above need to be considered in the assessment, handicaps often lead to invalidism, which
and should be part of the formulation. When affects the person's functioning including con-
needed, advice, information, and reassurance fidence and role in the area of sex. These issues
need to be given. The normality of continuing need to be addressed in therapy, and it is best
sex in later years may need to be emphasized. If done using cognitive techniques with the
there are fears or concerns about one's loss of individual and in joint counseling (cf. Malloy
attractiveness to the partner, some specific & Herold, 1986).
cognitive work on this will need to be under- When there is chronic handicap, the aim of
taken. therapy for sexual dysfunction should be to
The therapy program needs to take into maximize pleasurable sexual activity that is
account the clients' preferences and long- possible within the limits imposed by the
standing habits and practices, and any instruc- handicap. A couple may need to use only
tions for new and adventurous sexual activity certain coital positions, and variations within
should be given only after careful consideration these. Those who are paraplegic or quadraple-
and discussion. Greater emphasis on the gic, or who have a limited range of motion due
nongenital aspects of sexual activity may be to back problems or arthritis, need education
needed, and many elderly couples can learn to and advice on comfortable positions (cf.
find much sexual pleasure in this way. Specific Bullard, 1988). Sometimes the focus needs to
practical advice may include the use of be on noncoital sexual activities. Couples may
lubricants, when there is a female arousal need to be given carefully graded behavioral
disorder including lack of lubricationÐa very homework exercises, in which they can proceed
common presentationÐand on how vaginal at a slow pace and without fear of pain or risk of
penetration may be achieved even with a not fatigue. Some of these issues are discussed in
fully erect penis (Gillan, 1987). Finally, there are detail by Schover (1992), Schover and Jensen
instances when the presentation of a sexual (1988), and Spence (1991).
dysfunction in this age group is linked to anxiety
about not being able to perform as well as in 6.27.7.3 Gay Clients
previous years. This is particularly so with males
who may get concerned about their declining Presentation of gay men for help in sexual
erectile response. Part of the treatment would dysfunction is common (Reece, 1988). The
problems they present are varied, and cover the to ªbecome normal.º Any attempt to treat
full spectrum that is seen in heterosexual men sexual dysfunction while the client is still at a
(Bhugra & Wright, 1995). Etiological factors very low body weight is a mistake. The pace of
often include fear of HIV/AIDS, uncertainty therapy should be determined by the client's
about sexual orientation, and feelings of being readiness. Preliminary work on sex education
shunned or oppressed by society at large (cf. and attitudes may be needed (Van Vreckem &
Bhugra, 1987; Dupras & Morriset, 1993). In the Vandereycken, 1994). Individual work preced-
treatment of these clients, the general principles ing joint work is often advisable. Specific
of cognitive-behavioral sex therapy are applied, cognitive work on the significance of sex and
with special focus on the issues noted above. sexuality, the client's self-concept, and so on
Therapists need to be nonjudgmental in their may also be needed. Essentially, the therapy
attitude. When fear of sexually transmitted with this group of clients takes a slower, more
diseases are a part of the picture, clear advice on finely graded form than in general sexual
safe sex practices needs to be provided as part of dysfunction therapy. Examples of the treatment
the therapy package. of females with anorexia nervosa along these
In the treatment of gay clients without lines are found, among others, in Guile, Horne,
partners, a group approach may be considered and Dunston (1978) and de Silva and Todd
(cf. Reece, 1985). This format provides an (1998).
economical and effective way of dealing with
issues of stigma, ambivalence about sexual
orientation and so on, in addition to work on 6.27.8 SUMMARY AND COMMENTS ON
specific dysfunctions. Another issue that needs FUTURE DEVELOPMENTS
to be dealt with, in the treatment of gay men
without partners, is how one might get over the This chapter has reviewed the nature, diag-
fearÐand avoidanceÐof developing new rela- nosis, etiology, assessment, and treatment of
tionships, out of embarrassment about the sexual dysfunction. The field has developed
sexual dysfunction. Here, a behavioral rehearsal rapidly since the 1970s, with many practicing
may be used to provide practice in disclosing the clinical psychologists getting actively involved
dysfunction to a new partner (cf. McCarthy, in the clinical management of these problems,
1992). and in research aimed at elucidating them.
Work in this area is now very much part of
mainstream clinical psychology practice.
6.27.7.4 Women with Eating Disorders The current picture is, in essence, a promising
one. There is much in the literature to guide the
Females with eating disorders, especially practitioner in the clinical assessment and
anorexia nervosa, present a special challenge treatment of these difficulties. The outcome
to therapists. There is a very high incidence of literature is relatively weak, due to a variety of
sexual problems in women with anorexia factors. However, there is enough in the
nervosa (Beaumont, Abraham, & Simson, literature on the outcome of therapy for sexual
1981; Bancroft, 1989; de Silva & Todd, 1998; dysfunction to enable practitioners confidently
Raboch & Faltus, 1991). The reasons for this are to undertake the treatment of those patients
complex. Clearly, in severe anorexia nervosa who seek help for sexual problems.
endocrine factors are involved, and this affects As for the future, several developments can be
sexual functioning. There is also evidence that predicted. Many therapists have begun to use
many anorexic patients have anxieties about and develop cognitive techniques more exten-
sexuality and womanhood (cf. Anderson, 1985). sively in recent years, and this trend will
When they seek treatment, it is often for continue to grow. The incorporation of the
hypoactive female sexual disorder, or for systemic approach into a broad cognitive-
arousal disorder. Anorgasmia is also found as behavioral framework is another recent devel-
a problem, and not uncommonly sexual aver- opment that is likely to progress further. An
sion disorder (see de Silva & Todd, 1998). integrated approach deriving concepts and
There are major issues in the treatment of strategies from the cognitive-behavioral and
these clients. While the basic cognitive- the systemic traditions may well emerge as the
behavioral approach described in this chapter favored model in the near future. The other
forms the basis of therapy for them, its major area of development is likely to be in the
application has to be cautious and carefully physical treatments for sexual dysfunctions,
tailored to the individual. Often they come for mainly but not exclusively male erectile dys-
treatment with some ambivalence; they may function. Extensive and ambitious research is
come either due to the need to please their currently taking place in this area, and the
partner if they are in a relationship, or in order results of these investigations and trials are
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6.28
Relationship Problems
W. KIM HALFORD
Griffith University, Brisbane, Qld, Australia
HOWARD J. MARKMAN
University of Denver, CO, USA
and
PETER FRAENKEL
New York University, NY, USA

6.28.2 NATURE AND SIGNIFICANCE OF MARITAL DISTRESS 624
6.28.2.1 Prevalence of Marital Problems 624
6.28.2.2 Effects of Relationship Problems 624
6.28.3 NATURE AND ETIOLOGY OF RELATIONSHIP PROBLEMS 626
6.28.4 BEHAVIORAL, COGNITIVE, AND AFFECTIVE COMPONENTS OF RELATIONSHIP PROBLEMS 626
6.28.4.1 The Etiology of Relationship Distress 628
6.28.5 COUPLES THERAPY 629
6.28.5.1 The Different Approaches to Couples Therapy 630
6.28.5.2 Assessment of Relationship Problems and the Process of Couples Therapy 630
6.28.5.3 Cognitive-behavioral Couples Therapy 633
6.28.5.4 The Effectiveness of Cognitive-behavioral Couples Therapy 635
6.28.5.5 Couples Therapy and Psychological Disorder 636
6.28.6 PREVENTION OF RELATIONSHIP PROBLEMS 638
6.28.6.1 Prevention and Early Intervention 638
6.28.6.2 Content of Prevention Programs 639
Marriage is one of the most nearly universal of ships at some point in their lives. In Western
human institutions. No other touches so inti- countries over 90% of the population marry by
mately the life of practically every member of age 50 years (DeGuilbert-Lantione & Monnier,
the earth's population. (Terman, 1938, p.1) 1992; McDonald, 1995). Even among those who
choose not to marry, the vast majority engage in
6.28.1 INTRODUCTION ªmarriage-likeº relationships by living together
in committed, couple relationships (McDonald,
An overwhelming percentage of people 1995). Expectations of couple relationships are
become involved in intimate couple relation- high. In Western cultures the vast majority of
623
624 Relationship Problems
adults perceive their marital relationship as American, 42% of UK, and 37% of German
their primary source of support and affection end in divorce (De Gulbert-Lantoine & Mon-
(Levinger & Huston, 1990). Most young nier, 1992; McDonald, 1995). As painful as the
unmarried adults expect to marry at some point experience of divorce is for many people, most
in their lives, for that marriage to be lifelong, divorcees still aspire to be in a committed
and expect their partners to show sexual relationship. In the US about 75% of divorced
monogamy, honesty, expressions of affection, people remarry within five years of the end of
intimacy, and support (Millard, 1990). their first marriage (Glick, 1989; Martin &
Almost all couples that marry report high Bumpass, 1989). The divorce rates of second
levels of relationship satisfaction early in their marriages are even higher than for first
relationship (Markman & Hahlweg, 1993). marriages (Glick, 1989).
Many couples sustain a mutually satisfying Divorce rates represent only a portion of
relationship, and seem to derive many benefits couples experiencing relationship problems.
from that relationship. Relative to other people, Many couples have significant relationship
those in satisfying marriages have lower rates of distress, but opt to stay together for various
psychological distress, higher rated life happi- reasons such as the financial implications of
ness, and greater resistance to the detrimental divorce, and personal and cultural expectations
effects of negative life events (Glenn & Weaver, about marriage (Gottman, 1993, 1994). Surveys
1981; Gore, 1978; Gove, Hughes, & Style, 1983; of representative samples of married adults show
Halford, Kelly, & Markman, 1997). Unfortu- that between 80% and 85% report they are very
nately, for many other couples their relationship satisfied with their current relationship (Beach,
quality and satisfaction erodes over time. Arias, & O'Leary, 1986; Eddy, Heyman, &
Relationship problems spill over to negatively Weiss, 1991, Gallup, 1989; Reynolds, Rizzo,
affect partners' ability to cope with parenting Gallagher, & Speedy, 1979; Stanley & Mark-
and work outside the home, and this has major man, 1996). However, satisfied partners tend to
detrimental effects on them and their children make unrealistically positive comments and
(Halford & Markman, 1996; Sanders, Nichol- predictions about their relationship functioning
son, & Floyd, 1997). (Fowers, Lyons, & Montel, 1996). For example,
Seeking help about relationship problems is the majority of maritally satisfied partners
very common. Relationship preparation and believe there is zero probability that they will
enhancement programs are widely becoming ever divorce, despite the well-publicized evi-
accepted and attended by increasing propor- dence of how common divorce is (Fowers et al.,
tions of the population entering marriage 1996)
(Bradbury & Fincham, 1990; Stanley, Mark- Furthermore, of the married people who
man, Leber, & St. Peters, 1995; Simons, Harris, report high relationship satisfaction, 40% also
& Willis, 1994). In fact, relationship preparation report having seriously considered leaving their
programs are more widely attended than just current partners at some point (Gallup Poll,
about any other form of psychoeducational 1989), and over 50% are characterized by inter-
program (Simons et al., 1994). Couple relation- action patterns that erode satisfaction and
ship problems are one of the most common predict future divorce (Stanley & Markman,
presenting problem of adults seeking psycho- 1996). Thus, even those couples who report that
logical assistance (Veroff, Kulka, & Douvan, they are very satisfied in their relationship at any
1981), and couples often seek divorce mediation point in time are at risk for future problems and
when their relationships end (Emery & Wyer, divorce. All these figures converge on the point
1987; Walsh, Jacob, & Simons, 1995). In this that significant relationship problems are
chapter we analyze the nature and significance common in most Western societies.
of relationship problems, assessment of couple
relationships, the conduct of couples therapy,
and prevention of relationship problems. 6.28.2.2 Effects of Relationship Problems
Given the central importance placed upon
6.28.2 NATURE AND SIGNIFICANCE OF couple relationships, it is not surprising to find
MARITAL DISTRESS that relationship distress and dissolution are
experienced as extremely stressful events. In
6.28.2.1 Prevalence of Marital Problems fact, after a death in the immediate family,
marital distress and divorce are rated as the
The most statistically reliable index of marital most severe of commonly occurring stresses
distress is divorce rates, and divorce has reached experienced by adults (Bloom, Asher, & White,
epidemic proportions in most Western societies. 1978). Relationship distress is associated with
About 45% of Australian marriages, 55% of increased risk for development of a range of
Nature and Significance of Marital Distress 625
individual psychological disorders including effects mediated through health-related beha-

depression, particularly in women (Bebbington, viors, such as low adherence to medical
1987; Coyne, Kahn, & Gotlib, 1987; Hooley, treatment regimens by those in distressed
Orleay, & Teasdale, 1986), alcohol abuse, relationships (Schmaling & Sher, 1997).
particularly in men (O'Farrell, 1989), and Inadvertent reinforcement of illness behavior
anxiety disorders (Craske & Zoellner, 1995), in distressed marriages and inadequate support
and sexual dysfunction in both sexes (Zimmer, of coping in chronic illness can have a negative
1983). Marital conflict is also associated with impact upon partners' health (Schmaling &
increased behavior problems and poorer psy- Sher, 1997). There are also some direct effects of
chological adjustment in the couples' children relationship distress on physiological processes
(Emery, 1982; Emery, Joyce, & Fincham, 1987; which impact upon health. For example,
Grych & Fincham, 1990). relationship conflict is associated with immu-
The causal connections between marital nosuppression (Kiecolt-Glaser et al., 1993),
distress and individual psychological disorder elevated stress hormone levels (Keicolt-Glaser
are complex. Long-standing, psychological et al., 1996), elevated blood pressure in people
disorders reduce the chance of having a with essential hypertension (Ewart, Taylor,
satisfactory marriage. For example, patients Kraemer, & Agras, 1991), and possibly athero-
diagnosed with schizophrenia or severe person- sclerosis (Gottman, 1990; Medalie & Gold-
ality disorders are much less likely than the rest bourt, 1976). Each of these physiological effects
of the population to get married, and are much are likely to increase risk for serious health
more likely to get divorced if they do marry problems.
(Lange, Schaap, & van Widenfelt, 1993; Reich Relationship problems at home spill over to
& Thompson, 1985). However, the association work. More specifically, for men relationship
between marital problems and psychiatric conflict at home is associated with days lost at
disorder is not simply psychological disorder work and poor work performance (Thompson,
causing marital problems. For example, in cases 1997). The economic cost of the effects of
of coexisting marital problems and depression, relationship problems are extensive.
the marital problems often antedate the onset of Relationship violence has a major effect on
depression (Birchnall & Kennard, 1983). Even the health and well-being of many partners in
when treatment produces an improvement in committed relationships. About 25% of all
depressed mood there is limited effect on marital marriages have at least one episode of inter-
distress (Dobson, 1987; Klerman & Weissman, spousal physical aggression at some point
1982; O'Leary & Beach, 1990), and the ongoing (O'Leary et al., 1989; Strauss, Gelles, &
marital problems are associated with poor Steinmetz, 1980), and this violence almost
prognosis for the depression (Rousanville, always is associated with relationship distress.
Weissman, Prusoff, & Herceg-Baron, 1979). Over half of maritally distressed couples
Similarly, marital problems stimulate excessive presenting for therapy report having experi-
drinking (Davis, Berenson, Steinglass, & Davis, enced interpartner violence in the previous year
1974), precipitate relapse by people with high (O'Leary & Vivian, 1990). Whilst men and
alcohol dependence who have been abstinent women are equally likely to engage in aggressive
from alcohol consumption (Maisto, O'Farrell, acts such as hitting, pushing, or slapping
Connors, McKay, & Pelcovits, 1988), and are (Strauss & Gelles, 1986; O'Leary et al., 1989),
predictive of poor prognosis in alcohol treat- men are much more likely to engage in severe
ment programs (Billings & Moos, 1983; Vanni- violence, and women are at particular risk for
celli, Gingereich, & Ryback, 1983). Thus, a being injured or even killed by their partner
simple unidirectional model of causality is (Koop, 1985; Stets & Strauss, 1990). Even when
inadequate. Marital distress and psychological physical injuries are less severe, violence can
disorder reciprocally influence each other. have severe negative consequences for female
In addition to the psychological maladjust- victims. Women repeatedly assaulted by their
ment associated with relationship problems, partners are at high risk of developing depres-
relationship problems are also correlated with sion, alcohol abuse, psychosomatic disorders,
poorer physical health. Individuals in satisfying and are high users of the healthcare system
and supportive marriages are less likely to have (Cascardi, Langhinrichsen, & Vivian, 1992;
major illness, and they recover better when they Jaffee, Wolfe, Wilson, & Zak, 1986; Stets &
do become ill than individuals in distressed Strauss, 1990). Relationship aggression is also
relationships (Burman & Margolin, 1992; linked to child abuse (Grych & Fincham, 1990),
Schmaling & Sher, 1997). The mechanisms development of antisocial behavior in male
linking poor physical health to relationship offspring (Grych & Fincham, 1990), and
problems are complex and only partially under- increased risk of children entering a violent
stood. Relationship distress has some indirect relationship as an adult (Widom, 1989).
6.28.3 NATURE AND ETIOLOGY OF Active consideration of separation is com-

RELATIONSHIP PROBLEMS mon in couples with relationship problems,
(Weiss & Cerreto, 1980). However, the associa-
The common element to clinical presentation of relationship problems, consideration of
tions of relationship problems is almost always separation, and divorce is not straightforward.
dissatisfaction by at least one partner with the Most couples who eventually divorce go
relationship. Attempts to define and measure through a protracted process which proceeds
relationship problems have taken relationship from worsening relationship problems, through
(marital) satisfaction, as assessed by self-report active consideration of separation, to actual
inventories, as the ultimate criterion (Weiss & separation, and eventually to divorce (Gott-
Heyman, 1997). The most widely used self- man, 1990, 1993). Often in couple presentations
report inventories are the Locke±Wallace one or both partners are ambivalent about the
Marital Adjustment Test (Locke & Wallace, relationship and its future. Ambivalence can be
1959), and an expanded revision known as the a major challenge to the partners. They risk
Dyadic Adjustment Scale (Spanier, 1976). neither proceeding with separation nor working
These two scales, and many similar scales, have to improve a distressed relationship, and by
been subjected to repeated criticism (e.g., default the distress of the status quo is
Heyman, Sayers, & Bellack, 1994) for con- maintained. The systematic assessment of
founding relationship satisfaction, measured by relationship problem areas and strengths,
items such as ªoverall how would you rate your combined with conjoint goal setting, often
marital happiness,º with adjustment processes serves to overcome this inertia (Halford,
alleged to influence satisfaction, measured by Osgarby, & Kelly, 1996; Weiss & Halford,
items such as ªhow often do you and your 1995). We will say more on this in the section on
partner disagree about finances?º While the relationship assessment (Section 6.28.5.2).
collapsing of the constructs of relationship
satisfaction and adjustment seems conceptually
unsound, factor analyses of measures of marital 6.28.4 BEHAVIORAL, COGNITIVE, AND
adjustment and dissatisfaction consistently AFFECTIVE COMPONENTS OF
show that partners make unidimensional, RELATIONSHIP PROBLEMS
global evaluations of their relationship pro-
blems (Eddy, Heyman, & Weiss, 1991; Heyman Problems in communication are the most
et al., 1994). In essence, partners who are frequently cited specific complaint by couples
dissatisfied with their relationships tend to seeking therapy, with up to 90% of distressed
report that just about anything that could be couples citing these difficulties as a major issue
negative about their relationship is negative. in the relationship (Bornstein & Bornstein,
The finding that reported relationship distress 1986). Both independent observers and spouses
seems to reflect an overriding global evaluation report communication deficiencies are asso-
of negative aspects of the relationship does not ciated with relationship distress (Weiss &
mean that relationship quality is unidimen- Heyman, 1997). When discussing problem
sional. In the late 1990s work shows that couples issues, distressed partners are often hostile,
distinguish between dissatisfaction about nega- and criticise and demand change of each other
tive aspects of the relationship (e.g., the level of (Christensen & Shenk, 1991; Gottman &
distress associated with conflict) and satisfaction Krokoff, 1989; Gottman, 1994; Halford, Hahl-
with positive aspects of the relationship (e.g., the weg, & Dunne, 1990; Heavey, Christensen, &
sense of satisfaction with expressions of love) Malmuth, 1995; Notarius & Markman, 1993).
(Fincham, Beach, & Kemp-Fincham, 1997). Distressed couples also do not actively listen to
Some couples present with severe relationship their partner when discussing problems (Hal-
distress and little positive feeling about their ford et al., 1990; Jacobson, McDonald, Follette,
partner or the relationship, while other couples & Berley, 1985; Weiss & Heyman, 1990), and
are distressed by the negative aspects of the tend to withdraw from problem discussions
relationship associated with dissatisfaction but (Christensen & Shenk, 1991; Gottman, 1994;
still retain some positive feelings about the Gottman & Krokoff, 1989; Halford, Gra-
partner. The latter group of couples seem to vestock, Lowe, & Scheldt, 1992; Heavey,
benefit more from couples therapy (Hahlweg, Christensen, & Malmuth, 1995). Contentious
Schindler, Revenstorf, & Brengelman, 1984). In relationship issues are less likely to be resolved
either group of couples their initial focus often is by discussion in distressed couples than non-
on reducing negative behaviors associated with distressed couples (Halford et al., 1992).
dissatisfaction, but successful therapy also needs Distressed couples are highly reactive at an
to prompt couples to attend to developing emotional level to their partners' behavior, and
positive aspects of the relationship. show significantly higher rates of negative
Behavioral, Cognitive, and Affective Components of Relationship Problems 627
reciprocity during interaction than nondis- relationship distress cannot be understood

tressed couples (e.g., Gottman, Notarius, & simply in terms of the behaviors occurring
Markman, 1977; Schaap, 1984). In observa- during marital interaction, but also requires
tional studies of communication, the condi- attention to the cognitive appraisal by partners
tional probabilities of distressed partners of that interaction.
responding negatively to their partner's nega- Distressed couple have a number of char-
tivity is much higher than the conditional acteristic cognitions about their relationships
probabilities for nondistressed partners (e.g., (Beaucom, Epstein, Sayers, & Sher, 1989).
Halford et al., 1990). In addition to this negative Maritally distressed couples selectively attend
reciprocity, relationship distress is also asso- to their partner's negative behavior (Eidelson &
ciated with high levels of psychophysiological Epstein, 1982; Floyd & Markman, 1983;
arousal during interaction (e.g., Gottman & Jacobson & Moore, 1981), and selectively recall
Levenson, 1988). This arousal is aversive, which such negative behavior (Halford & Osgarby,
may explain the higher rates of withdrawal 1996). In contrast, maritally, satisfied partners
during problem-focused discussions by mari- tend to overlook negative behaviors by their
tally distressed partners (Christensen & Shenk, spouses (Gottman et al., 1977; Notarius,
1991; Gottman & Krokoff, 1989). In any case, Benson, Sloane, Vanzetti, & Horyak, 1989),
both the extent of arousal and the frequency of to have an unrealistically positive view of their
withdrawal prospectively predict deterioration partners and relationships (Fowers, Applegate,
in marital satisfaction (Gottman, 1993; Gott- Olson, & Pomerantz, 1994), and to selectively
man & Krokoff, 1989; Heavey, Layne, & recall positive aspects of relationship interaction
Christensen, 1993; Heavey et al., 1995). (Halford & Osgarby, 1996).
Another common complaint of couples Another characteristic of distressed couples
seeking relationship therapy is the negativity in the cognitive domain is holding unrealistic
of their day-to-day interactions (Halford, in beliefs about relationships and partners. More
press). Using behavioral checklists in which specifically, relative to happy couples, distressed
partners monitor their spouses' behavior there couples are more likely to believe that any form
is a well-replicated finding that monitored daily of disagreement is destructive, that change by
behaviors correlate with relationship satisfac- partners is not possible, and that rigid adher-
tion (Birchler, Weiss, & Vincent, 1975; Halford ence to traditional gender roles is desirable
& Sanders, 1988; Jacobson, Follette, & McDo- (Baucom & Epstein, 1990; Eidelson & Epstein,
nald, 1982; Johnson & O'Leary, 1996). More 1982). Distressed couples also report that their
specifically, relative to maritally satisfied cou- relationships often violate standards about how
ples, distressed couples report higher rates of they think their relationship should be (Baucon
negative, displeasing behaviors by their spouse et al., 1996). For example, distressed women
and fewer positive, pleasing behaviors (Birchler report that their partners do not share power
et al., 1975; Halford & Sanders, 1988; Jacobson within the relationship in the manner the
et al., 1982; Johnson & O'Leary, 1996). women believe they should, and men believe
Furthermore, distressed couples tend to reci- their partners should invest more time and
procate on a quid pro quo basis the behaviors of energy in the relationship than they do (Baucom
their spouse. In other words, in a distressed et al., 1996).
relationship partners tend only to be positive if Distressed couples attribute the causes of
their partner recently has been positive, and if relationship problems to stable, internal, nega-
one partner behaves negatively the other often tive, and blameworthy characteristics of the
responds negatively immediately (Birchler et al., partners (Bradbury & Fincham, 1990; Fincham
1975; Jacobson et al., 1982). In contrast, & Bradbury, 1992). For example, a partner
satisfied couples' behavior is less contingent arriving home late from work may be perceived
on the preceding partners' behaviors; satisfied as ªa generally selfish person who doesn't care
couples tend to be positive irrespective of their about the familyº by a maritally distressed
partners' prior actions. partner. The same behavior may be attributed
There also is evidence that distressed couples' by a maritally satisfied partner as the spouse
perceptions of their partners' behavior are ªstruggling to keep up with a heavy load at
negatively biased. Distressed couples disagree work, and being subject to lots of pressure from
to a greater extent with both objective observers the boss.º The process of attributing much or all
(Robinson & Price, 1980) and with each other of the relationship problems to their partners
(Christensen & Nies, 1980; Jacobson & Moore, leaves most people with relationship distress
1981) regarding the occurrence of particular feeling powerless to improve their relationship
behaviors in their relationship. More specifi- (Vanzetti, Notarius, & NeeSmith, 1992). A key
cally, they tend to overestimate the frequency of element of couples therapy is to enhance each
negative partner behaviors. The nature of partners' sense of relational efficacy or capacity
to improve their relationship through their own et al., 1989), at least for mild to moderate severity
actions (Halford, Sanders, & Behrens, 1994). aggression. Relationship aggression is often
One additional cognitive characteristic of a established early in the relationship, and usually
distressed couple is that they expect negative continues and escalates once established (Mur-
outcomes from interaction with their partners. phy & O'Leary, 1989; O'Leary et al., 1989).
Distressed couples report that prior to a It is noteworthy that the communication and
discussion they expect not to be able to resolve conflict management deficits observed in some
problem issues in their relationships (Vanzetti engaged couples do not correlate with their
et al., 1992). In anticipation of a problem- reported relationship satisfaction or commit-
solving discussion, maritally distressed partners ment at the time (Markman & Hahlweg, 1993;
show high physiological arousal (Gottman, Sanders, Halford, & Behrens, 1996). It seems
1994), negative affect, and become primed to that these communication difficulties do not
access negative evaluative judgements about stop couples from forming committed relation-
their partner and the relationship (Fincham, ships, but the difficulties do predispose couples
Garnier, Gano-Phillips, & Osborne, 1995). to develop relationship problems later. In
The cognitive characteristics of distressed couples who have been married for some time,
couples mediate their subsequent behavior these same communication difficulties predict
toward their partners. For example, the occur- deterioration in relationship satisfaction and
rence of negative attributions is associated with decreased relationship stability (Gottman,
subsequent behavioral negativity (Bradbury & 1993, 1994)
Fincham, 1992). In unhappy couples, negative The beliefs and expectations individuals have
thoughts about the partner predict future when entering into relationships and marriage
negative behaviors better than predictions from predict the risk of divorce in the first few years of
previous behavior (Halford & Sanders, 1990), marriage (Olson & Fowers, 1986; Olson &
suggesting these cognitions are more than just Larsen, 1989). Couples characterized by un-
the consequences of negative marital behavior. realistic expectations and beliefs in areas such as
In other words, relationally distressed partners importance of communication, appropriate
seem to respond to their subjective perceptions methods of conflict resolution, importance of
and memories of relationship interactions, and family and friends, and gender roles, have
these perceptions and memories are negatively higher rates of erosion in relationship satisfac-
biased. tion than couples not so characterized. Negative
attributional patterns in which partners attri-
6.28.4.1 The Etiology of Relationship Distress bute blame for relationship problems to stable,
negative characteristics of their spouse also
There are over 100 published studies assessing prospectively predict deterioration in relation-
the longitudinal course of couple relationship ship satisfaction (Fincham & Bradbury, 1990).
satisfaction and stability (Karney & Bradbury, Thus, certain communication and cognitive
1995). This comprehensive literature can be characteristics of the couple's adaptive pro-
usefully summarized in terms of three broad cesses predate, and prospectively predict, re-
classes of variables which impact upon the lationship problems.
etiology of relationship problems: adaptive Stressful events refer to the developmental
processes within the couple system, stressful transitions and acute and chronic circumstances
events impinging upon the couple system, and which impinge upon the couple or individual
enduring individual vulnerabilities of the part- partners. Relationship problems are more likely
ners (Bradbury, 1995). to develop during periods of high rates of change
Adaptive processes refer to the cognitive, and stressful events (Karney & Bradbury, 1995).
behavioral, and affective processes that occur For example, the early stages of marriage,
during couple interaction. Certain deficits in including transition to parenthood, is often
these adaptive processes seem to predispose associated with decline in couple relationship
couples to relationship problems. More specifi- satisfaction (Cowen & Cowen, 1992), as is an
cally, deficits in communication and manage- increase in work demands (Thompson, 1997).
ment of negative affect and conflict observed in Retirement is another major transition for
engaged couples prospectively predict divorce couples which can be associated with relation-
and relationship dissatisfaction over the first 10 ship distress (Dickson, 1997). One partner
years of marriage (Markman & Hahlweg, 1993). developing a major health problem also puts
Dysfunctional communication and negative couples at increased risk for relationship and
affect regulation in engaged couples also pre- sexual problems (Schmaling & Sher, 1997).
dicts the development of relationship verbal and A common stressful transition worthy of
physical aggression in the first few years of special mention is entering a second marriage.
marriage (Murphy & O'Leary, 1989; O'Leary Second marriages in which there are dependant
Couples Therapy 629
children from an earlier relationship break and subsequently these learned behaviors im-
down at very high rates (Booth & Edwards, pact negatively upon the adult relationships of
1992; Martin & Bumpass, 1989). Negotiating the offspring. The argument that communica-
parenting roles in step-families is a common tion difficulties may be acquired through
source of interpartner conflict, and unresolved observation and interaction with parents is
differences in this area are the most common supported by a finding from Howes and Mark-
stated reason for relationship breakdown in man (1991). They found couple communication
step-families (Lawson & Sanders, 1994). More- style assessed premaritally predicted subsequent
over remarital partners tend to repeat the same communication style when the partners become
patterns of negative interactions with their new parents and were interacting with their children
partners despite efforts to the contrary (Prado (Howes & Markman, 1991).
& Markman, in press). The association between personality vari-
In general, couples with less robust adaptive ables and relationship problems has been widely
processes are believed to be particularly vulner- studied. Normal personality variations do not
able to the negative effects of a range of stressful seem to contribute much variance to relation-
events (Markman, Halford, & Cordova, 1997). ship satisfaction (Gottman, 1994; Karney &
In particular, couples who lack communication Bradbury, 1995; Notarius & Markman, 1993).
skills, or who have inflexible or unrealistic One exception is that low ability to regulate
expectations of relationships, find it hard negative affect (high neuroticism) consistently
negotiate the changes required to adapt to has been found to predict higher risk for
major life transitions (Markman, Stanley, & relationship problems and divorce (Karney &
Blumberg, 1994). For example, one of us Bradbury, 1995). How this personality char-
(WKH) is studying couples where the women acteristic may impact upon relationship pro-
were recently diagnosed with breast or gyneco- blems is not yet understood.
logical cancer. In couples with good commu- Another major risk indicator for relationship
nication and effective mutual support the distress and divorce is past or present history of
adversity of cancer diagnosis and treatment psychological disorder. Higher rates of relation-
seems to bring the couples closer together and ship problems and divorce consistently have
reinforce the relationship bonds. In contrast, been reported in populations with severe
couples with poor adaptive processes show psychiatric disorder (Halford, 1995), and in
deterioration in their relationships and poor people with depression, alcohol abuse, and
individual coping with the cancer. some anxiety disorders (Emmelkamp, De Haan,
Enduring vulnerabilities refer to the stable & Hoogduin, 1990; Halford, Kelly, Bouma, &
historical, personal, and experiential factors Young, in press; Halford & Osgarby, 1993;
which each partner brings to a relationship O'Farrell & Birchler, 1987; Reich & Thompson,
(Bradbury, 1995). Family of origin experiences 1985; Ruscher & Gotlib, 1988; Weissman,
have been widely studied as historical factors 1987). As described earlier in this chapter,
which correlate with risk of relationship pro- relationship problems and individual problems
blems. For example, the adult offspring of can both exacerbate each other (Halford et al.,
divorce are more likely than the rest of the in press). In addition, certain personal vulner-
population to divorce (Glenn & Kramer, 1987), abilties may dispose people to both psycholo-
and interparental aggression is associated with gical disorders and relationship problems. For
increased risk for having an aggressive relation- example, deficits in interpersonal communica-
ship as an adult (Widom, 1989). The mechanisms tion and negative affect regulation are risk
by which exposure to parental divorce or factors that predict the onset of both alcohol
aggression may impact upon subsequent adult abuse (Block, Block, & Keyes, 1988) and
relationships is becoming clearer. Exposure to relationship problems (Markman & Hahlweg,
parental divorce is associated with more nega- 1993). This common risk factor might be part of
tive expectations of marriage (Black & Sprenkle; the explanation for the common co-occurrence
1991; Gibardi & Rosen, 1991; Van Widenfelt, of relationship and alcohol problems.
Schaap, & Hosman, 1996), and with observable
deficits in communication and conflict manage-
ment in couples prior to marriage (Halford et al., 6.28.5 COUPLES THERAPY
1994). Adult offpsring of parents who were
aggressive also show deficits in communication, Intervention with relationship problems can
and conflict management skills in dating and potentially target couples' adaptive processes,
marital relationships (Sanders, Halford, & stressful events, or enduring vulnerabilities, as
Behrens, 1998; Skuja & Halford, 1998). Negative each of these classes of variables influence
expectations and communication deficits may relationship problems. The focus of all inter-
well be learned from the parents' relationships ventions evaluated in research has been on
modifying couples' adaptive processes, either interactions through cognitive change proce-
through conjoint therapy for couples with dures and attempts to change relationship
existing relationship problems (e.g., Baucom interactions with behavioral procedures (e.g.,
& Epstein, 1990; Halford, in press), or through Baucom & Epstein, 1990; Halford et al., 1993).
brief programs to prevent the development of The distinctions between these different
relationship problems (Halford & Behrens, empirically validated approaches to couples
1996; Markman & Hahlweg, 1993). Often therapy are becoming somewhat blurred. Treat-
interventions are adapted to take account of ment manuals written for insight-oriented
the enduring vulnerabilities of the partners. For couples therapy (Snyder & Wills, 1989) include
example, there has been considerable research considerable use of behaviour change proce-
on therapy with couples in which one partner dures that seem identical to those used in
has depression (Beach, Sandeen, & O'Leary, cognitive-behavioral couples therapy (Jacob-
1992) or alcohol abuse (O'Farrell & Rotunda, son, 1991; Markman, 1991). Treatment man-
1997). In the 1990s some work has focused on uals published by cognitive-behavioral couples
developing couples' adaptive processes to therapists (Christensen, Jacobson, & Babcock,
manage particular life transitions and stressful 1995; Weiss & Halford, 1995) describe the
events, such as being in a step-family (Lawton & limitations of relying on changing relation-
Sanders, 1994). In the rest of this chapter we ship interactions and incorporate procedures
focus on interventions targeting change in acknowledged as very similar to those ad-
couple adaptive processes. vocated by emotion-focused therapists to
change the subjective experience of relation-
ship interactions.
6.28.5.1 The Different Approaches to Couples While there is some blurring of the distinc-
Therapy tions between different theoretical approaches
to couples therapy, there are still some
A number of different approaches to couples important differences in such approaches. The
therapy, including behavioral, cognitive, most widely used approaches to couples therapy
cognitive-behavioral, emotion-focused, and in clinical practice are systemic and strategic
insight-oriented couples therapy, have been approaches (Boughner, Hayes, Bubenezer, &
demonstrated to improve the relationship West, 1994), and there are a diversity of
satisfaction of the majority of couples who procedures used within these approaches
present for therapy (Baucom & Epstein, 1990; (Fraenkel, 1997). There is little evidence by
Greenberg & Johnson, 1988; Hahlweg & Mark- which to judge how useful these procedures are.
man, 1988; Halford, Sanders, & Behrens, 1993; In contrast, relatively few practitioners use the
Shadish et al., 1993; Snyder, Wills, & Grady- most extensively researched approach to cou-
Fletcher, 1991a). All these approaches share the ples therapy: cognitive-behavioral couples ther-
characteristics of the use of systematic assess- apy (CBCT) (Markman, Halford, & Cordova,
ment and goal setting at the beginning of ther- 1997; Shadish et al. 1993). As we believe in
apy, and a focus on conjoint therapy targeting practice being guided by research, the couples-
changes in the couples' adaptive processes. therapy approach outlined in this chapter is
The different theoretical approaches to based on the CBCT approach, which has
couples therapy which have empirically vali- developed from the research foundation we
dated efficacy have placed different emphases reviewed earlier in this chapter.
on the processes alleged to produce change in
couples' adaptive processes. In insight-oriented
and emotion-focused couples therapy emphasis 6.28.5.2 Assessment of Relationship Problems
was placed on changing partners' subjective and the Process of Couples Therapy
experience of relationship interactions, usually
through insights gained into the subjective Clinical descriptions of cognitive-behavioral
significance of particular relationship events couples therapy emphasize the importance of
(Greenberg & Johnson, 1988; Snyder, Wills, & developing therapeutic alliances with each
Grady-Fletcher, 1991b). In contrast, in beha- partner, developing a shared understanding of
vioral approaches to couples therapy the relationship problems and goals which pro-
original emphasis was on changing relationship motes adaptive change, and explicit negotiation
interaction through procedures such as beha- with couples about their roles in therapy (e.g.,
vioral contracting and skills training in areas Beach, Sandeen, & O'Leary, 1990; Baucom &
such as communication and problem-solving Epstein, 1990; Christensen et al., 1995; Weiss &
(Jacobson & Margolin, 1979). Cognitive beha- Halford, 1995). Assessment is crucial in
vioral couples therapy combined attempts to achievement of these process outcomes in
change the subjective experience of relationship couples therapy. In essence, the therapist seeks
Couples Therapy 631
through assessment both to establish an the descriptions and conclusions being reached
empathic understanding of each partner's are accurate according to each partner. After
experience of the relationship and to promote presenting all the key findings the therapist
a shared conceptualization of problems in terms summarizes the results and discusses with the
of relationship interactions. The shared con- couple possible goals for therapy. The most
ceptualization is the basis for the participants to commonly identified goals are improving com-
negotiate the goals of therapy and to determine munication, controlling conflict, enhancing
how those goals are to be achieved. quality time together, and renegotiating key
Establishing a shared conceptualization of relationship responsibilities. Other common
relationship problems sometimes is a difficult goals include working together to improve
therapeutic task. Therapists tend to see relation- parenting difficulties, enhancing support for
ship problems in terms of the adaptive processes each other, and enhancing the expression of
occurring between the partners. In contrast, intimacy and closeness.
couples often enter therapy conceptualizing After developing a shared relationship focus,
their relationship problems as due to stable, the next step in couples therapy is to have each
global negative characteristics of their partners partner define what she or he can do to change
(Fincham & Bradbury, 1990), and believe there problematic interactions. This emphasis on self-
is little they can do individually to improve their change (also known as self-regulation) focuses
relationship. therapy on that which each client has the most
To achieve a shared, productive relationship direct control over, namely their own behavior
focus in couples therapy the therapist initially (Halford, Sanders, & Behrens, 1994). This is not
assesses the presenting concerns from the to say that changes in the partner are unim-
perspective of each partner. Often these initial portant, but rather that the most productive
descriptions by clients are critical and blaming of method of achieving change is for each partner
the partner (e.g., ªhe does not communicate,º to focus on their own opportunities to change.
ªshe is too demandingº). The therapist then uses For some couples the process of assessment,
a variety of strategies to promote a relationship plus one or two sessions focused on self-directed
focus. For example, strategic use of questioning goal setting and change, can be sufficient to
can promote attention to relationship interac- improve a distressed relationship (Halford et al.,
tion (e.g., ªHow do you two resolve conflict?º 1996). For other couples, assessment is just the
ªAs a couple how do you ensure you have quality beginning of a more extensive therapeutic
time together?º). Particular assessment tasks process, but serves the crucial function of
also prompt attention to relationship interac- determining the directions for therapy.
tion. For example, undertaking certain commu- Assessment provides two kinds of informa-
nication tasks can be used to identify strengths tion: content and process. Content information
and weaknesses in communication. Reframing refers to the reports of the concerns of the
summaries also can foster a relationship focus. partners, such as the specific content of conflicts,
For example, suppose a couple argue about or their current thinking or actions about
parenting. One partner may present this issue as separation. Process information samples how
ªhe is too soft on the children when they the couple respond to the various probes or tasks
misbehave.º The spouse might describe the issue the therapist initiates. For example, if the couple
as ªshe is too harsh in her discipline of the are asked to discuss an issue of relevance to the
children.º The therapist may summarize this as: relationship, the therapist may be particularly
ªas a couple you struggle to agree on the best interested in either the process of interchange
ways to manage your children's behavior.º The between the partners (e.g., the degree of effective
therapist's summary reframes the issue as a listening to each other's perspective) or the
relationship challenge the couple can work on actual content of the discussion.
together. Many therapists rely exclusively on conjoint
In CBCT there is a strategic separation of interviews with the couple to assess the content
assessment and therapy. At the completion of of relationship problems (Boughner, Hayes,
assessment the therapist provides the couple Bubenezer, & West, 1994). This is a mistake.
with structured feedback on the results of the Content information obtained from conjoint
assessment. This feedback summarizes and interviews is less reliable than information
integrates the assessment information and derived from either individual interviews or
focuses the results on how the problems can self-report inventories (Haynes, Jensen, Wise, &
be conceptualized within a relationship frame- Sherman, 1981). For example, physical abuse is
work. The process typically involves the dramatically under-reported in conjoint inter-
therapist presenting the results of the assess- views relative to either self-report inventories or
ment to the couple, one assessment instrument individual interviews (O'Leary, Vivian, & Mal-
at a time. The therapist continually checks that one, 1992). Furthermore, encouraging couples
to recount lengthy lists of complaints about their The second phase of the intake interview is
partners in the presence of the partner rarely then done with each individual partner, cover-
promotes a collaborative set to move therapy ing the key areas identified in Table 1. The goal
forward. Consequently, we recommend that a in this phase is to identify key areas of concern,
combination of self-report inventories and and to establish an empathic relationship with
individual interviews be used to assess content each partner. The third phase brings the couple
information, and that conjoint interviews be back together again. In the third phase the
focused on assessment of process. therapist summarizes the key concerns identi-
A structure for an initial interview which fied by each partner. These summaries need to
illustrates the combination of process and express the concerns in a manner consistent with
content assessment is outlined in Table 1. The the experience of each partner, and in a manner
session begins with a brief conjoint interview in that allows mutual agreement that particular
which the agenda for the session is negotiated. areas need attention. For example, the therapist
At the beginning the therapist should ask the might describe areas of disagreement as identi-
couple an open-ended question about the fied areas requiring further negotiation. Both
reasons they are seeking assistance. When partners can agree these are issues that they need
posing the question it is often helpful for the to resolve.
therapist to get eye contact with both partners, Table 2 is a summary of key areas of
and then look at a point midway between the relationship problems which need assessment,
partners as the question is finished. The goal at and some useful assessment instruments for
this point is to establish if the couple can each of those areas. The process of assessment
collaborate and conjointly tell a coherent story typically involves each partner completing the
about their relationship problems. If each various self-report inventories and behavioral
partner allows the other to speak, and there is monitoring tasks between therapy sessions. The
mutual respect, then a conjoint intake interview therapist reviews and discusses the information
may be possible. More commonly, in couples each partner provides. In addition, the therapist
with relationship problems, the response to this often sets the couple particular tasks within
initial probe is escalating conflict in the session, sessions. A common assessment procedure is to
with each partner being blaming and negative have couples undertake one or more commu-
toward the other. The therapist should inter- nication tasks, such as discussing a source of
vene promptly to stop such escalation. The disagreement within the relationship. This is
therapist also needs to note that the couple need best done with the therapist outside the room
to develop a mutually acceptable way of talking observing via one-way screen or videorecording
about their problems if therapy is to proceed where available. The goal is to assess how the
successfully. couple communicate and manage conflict.
Further detail on these assessment tasks are
Table 1 Structure of couples initial interview. available in O'Leary (1977), Baucom and
Epstein (1990), and Halford (in press).
Initial orientation (10 minutes) The assessment process is more than just
Introduction passive collection of information. In the process
Present structure of session of assessment the therapist is working with the
Ask for a brief/joint statement of problem partners to develop an agreed on concept of the
Individual interviews (30 minutes each) relationship problems which facilitates change.
Current status of relationship The completion of assessment tasks often
Sources of difficulty prompts each partner to consider aspects of
Specific areas: their relationship in new ways. For example, as
behavior changes for self/partner noted earlier, many partners in distressed
communication relationships attribute the causes of their
time use relationship problems to their partner, and feel
sex powerless to change the things that distress
external stressors them. In a version of the Areas of Change
individual problems
domestic violence
Questionnaire (Weiss & Halford, 1995), each
separation partner is asked to identify behaviors they
commitment personally need to change to enhance their
relationship. Just posing the question of self-
Joint session (20 minutes) change in a structured way can help the person
Review individual material
Describe behavioral couples therapy approach
to generate change ideas. Similarly, the experi-
Review suitability of behavioral couples therapy ence of a communication assessment task can
Logistics of therapy prompt partners to identify aspects of their own
communication behavior they wish to change.
Couples Therapy 633
Table 2 Key areas of assessment for couples therapy.
Area Example measure Explanation
Relationship satisfaction Dyadic Adjustment Scale Level of distress, global evaluations of

(Spanier, 1976): 31-item self- relationship
report inventory
Divorce potential Marital Status Inventory (Weiss Steps toward separation, high steps
& Ceretto, 1980); a 14-item predict poor prognosis
rating scale
Behavior exchange Areas of Change Questionnaire Current patterns of daily interaction,
(Weiss & Perry, 1983); 34 items identify behavior change preferences
rating extent of requested of each client
behavior change by a partner
Communication and The most common presenting concern,
conflict management and a key area requiring attention in
much couples therapy
Aggression and violence Conflict Tactics Scale (Strauss, Verbal, psychological, and physical
1979) aggression between partners
Relationship standards Baucom et al. (1996) The expectations partners have of each
and beliefs other and relationships. Often
unrealistic beliefs can be a source of
relationship problems
The assessment process needs to move couples order to self-select and implement self-change
stuck in a partner-blaming focus for distress to a goals to enhance the relationship (Halford et al.,
relationship focused view of the problems. 1994; Weiss & Halford, 1995). Although the
Ultimately the goal is to have each partner details of the procedures have been refined, an
take responsibility for self-directing personal emphasis on changing relationship behaviors
change to enhance the relationship (Halford remains an important element of how CBCT
et al., 1994). attempts to alter couples' adaptive processes.
In Table 3 some of the key behaviors identified
as promoting long-term satisfying relationships
6.28.5.3 Cognitive-behavioral Couples Therapy are identified. In couples therapy partners are
helped to self-identify behaviors that they wish
Based upon the premise that a relationship is to change within these different domains to
defined by the exchange of behaviors between enhance their intimacy with their partner. There
partners, CBCT began as the application of are several ways of doing this. For example,
behavioral contracting to the treatment of partners can be asked to self-monitor behaviors
relationship problems. Couples were trained within a given class and then to identify
to monitor their partners' behavior and, based behaviors they wish to increase in that domain.
on such assessments, contingency contracts A second example is the Caring Days Exercise
were developed to reduce displeasing and (Weiss & Halford, 1995). In this procedure each
increase pleasing behaviors within the relation- person is encouraged to identify some small
ship (e.g., Azrin, Naster, & Jones, 1973; Stuart, specific behaviors which they can do which
1969; Weiss, Hops, & Patterson, 1973). Such demonstrate caring for their partner. To en-
contracting initially stressed tightly structured hance their ability to self-select appropriate
quid pro quo agreements, in which spouses were caring behaviors, partners can be assisted to be
taught systematically and immediately to more creative in generating ideas. For example,
reward desired behavior from the partner to enhance creativity people can brainstorm
(Azrin et al., 1973; Stuart, 1969). This was later ideas, they can ask their partner what would
replaced by unilateral ªgood faithº contracts in demonstrate caring effectively to them, they can
which partners were asked to undertake positive ask friends about caring behaviors that they
change for the good of the relationship (e.g., engage in within their relationships, they can
Gottman, Notarius, Markman, & Gonso, 1976; observe others demonstrating caring in their
Weiss, Birchler, & Vincent, 1974). Subse- normal day-to-day lives, or they can read
quently, emphasis has been placed on each through checklists of ideas and suggestions
partner actively seeking out information in provided by the therapist. The self-regulatory
focus encourages each person to take individual phrasing, minimal encouragers) and relation-
responsibility for being creative in identifying ship problems (Halford et al., 1990, 1993).
behaviors that they will engage in and to set Rather, it seems that there are a few broad
themselves tasks of implementing behavioral classes of adaptive relationship communication
changes. behaviors, such as validation (active, positive
A second element of CBCT is communication listening to partner) and positive engagement,
and problem-solving skills training. These skills and use of any of a wide variety of behaviors
are conceptualized as providing couples with the within these broad classes is associated with
means to enhance intimate communication and improvements in relationship problems (Sayers,
resolve their current and future sources of Baucom, Sher, Weiss, & Heyman, 1991). The
conflict (Jacobson & Margolin, 1979; Notarius specific behaviors within the broad classes
& Markman, 1994). In most applications of which are functional vary across relationships,
CBCT the communication skills targeted in time and settings (Halford, Gravestock, Lowe,
training have been identified by the therapist & Scheldt, 1991). In other words, different
based upon contrasting the couple's current communication styles suit different relation-
communication with a model of adaptive ships and circumstances, but we can be reason-
marital communication. The models of adaptive ably confident that an adaptive communication
marital communication were derived, in large style will need to involve validation and positive
part, from research contrasting the communica- engagement. Furthermore, successful couples
tion behaviors of maritally distressed and do not always use these skills after intervention,
nondistressed couples in problem-solving inter- but do so when needed (Hahlweg & Markman,
actions within research laboratories (see Weiss 1996).
& Heyman, 1990, 1997, for reviews of this A crucial skill in couple interaction is
literature). Often CBCT would teach couples a management of negative affect. In successful
relatively fixed curriculum of skills (e.g., para- long-term relationships, partners must both be
phrasing, asking open-ended questions, beha- able to manage their own negative feelings and
vioral pin-pointing), based on the assumption respond constructively to their partner's nega-
that each of these skills were adaptive as tive feelings (Markman, Stanley, & Blumberg,
communication skills. 1944). One negative interaction erodes the effect
Research shows that there is no clear of 5±10 previous positive interactions (Notarius
relationship between the use of particular, & Markman, 1994), so preventing destructive
specific communication behaviors (e.g, para- negativity is crucial.
Table 3 Classes of behavior most strongly related to marital satisfaction.
Class of behavior Examples
Affection Saying ªI love youº

Giving a hug or kiss
Enjoying a shared laugh or joke
Saying they enjoy partner's company
Respect Listening to the partner's opinion
Telling partner of admiration/respect
Showing confidence in partner's abilities
Introducing partner to others with pride
Support Doing errands for partner
Making self available to do work for partner
Asking partner about their day
Doing something to save partner time/energy
Communication of ideas Telling partner about their day
Discussing topical events
Giving an opinion
Talking about mutual interest(s)
Shared quality time Spending an hour or more just talking
Work together on a project
Take a drive or walk
Go out together, just the two of you
Discuss personal feelings
Couples Therapy 635
Applying the self-regulation approach to behavior change to alter relationship interac-

communication skills, each partner is assisted tion and change in the subjective experience of
to self-select goals for changing his or her own existing relationship interactions.
communication, and to self-evaluate his or her The CBCT approach to relationship dissa-
own communication. For example, clients tisfaction usefully can be summarized within an
review their own couples discussions (e.g., an extension of the self-regulation framework
audiotape of a conversation at home on a proposed by Halford et al. (1994). Subjective
difficult topic) with the therapist in sessions, dissatisfaction with your relationship can be
with partners each focusing on their own responded to in one of five ways. First, you can
communication. This maintains the therapeutic alter the ways in which you attempt to persuade
focus on what the client can change (i.e., his or your partner to change, so that you get change.
her own behavior). Based on the assumption Second, you can alter your own behavior to
that adaptive marital communication is defined enhance relationship functioning. These first
by its functional impact within the relationship, two options were the focus of traditional
self-directed attempts at changes in commu- behavioral couples therapy, producing behavior
nication are seen as behavioral experiments. change through procedures such as behavioral
Consequently, when a partner makes a change contracting and negotiation. Third, you can
in communication that produces a negative alter your own subjective response to negative
outcome (e.g., making an assertive rather than aspects of relationship interactions so that those
aggressive request for change by the partner aspects are less stressful and you feel no pressing
when discussing a particular issue elicits verbal need for change. This is what Christensen et al.
abuse from the spouse), this shows that (1995) call acceptance. Fourth, you can decide
assertion was not adaptive in this context, that particular existing behaviors are unaccep-
and a different approach is needed. table, intolerable, and unchangeable, and that
A third element of CBCT is altering sub- you will therefore leave the relationship.
jective experience of relationship interaction. Finally, you can do nothing, and maintain the
Although CBCT always included recognition of status quo. In our experience few clients have
the importance of internal mediators of external explored all these options for individual action.
experience (Weiss, 1984), more recent develop-
ments have placed greater emphasis on cogni-
tive and affective change strategies. Many of 6.28.5.4 The Effectiveness of Cognitive-
these strategies apply standard cognitive ther- behavioral Couples Therapy
apy procedures to relationship problems. For
example, self-instructional strategies are used to CBCT consistently has been shown to be
modify negative attributions (Baucom & Lester, superior to no treatment or therapist contact
1986) or control anger (Schindler & Vollmer, control conditions in reducing marital distress
1984), and guided discovery, Socratic dialogue (Hahlweg & Markman, 1988; Markman &
and behavioral experiments are used to chal- Hahlweg, 1993). More specifically, CBCT
lenge irrational relationship beliefs (Baucom & improves couples' communication skills, re-
Epstein, 1990; Halford, in press). duces destructive conflict, enhances positivity of
The greater emphasis on changing subjective day-to-day interactions, and increases the
experience in CBCT is particularly evident in positivity of couples' cognitions about their
recent changes in managing destructive conflict partners and their relationships (Hahlweg &
within distressed couples. Earlier versions of Markman, 1988; Halford et al., 1993). In other
CBCT emphasized teaching communication words, CBCT is effective in changing the key
and problem-solving skills to reduce conflict. identified risk factors for marital distress.
More recently, emphasis has been placed on Among couples who present for couples
exploring with each partner the attributions, therapy, the negative effects of relationship
meaning, and significance attached to the issues distress usually are already evident (Bloom,
which are sources of conflict (e.g., Christensen 1985). For example, alcohol abuse and depres-
et al., 1995; Weiss & Halford, 1995). While there sion are common in partners seeking marital
are variations in the details of the therapeutic therapy, as are behavior problems in the
process used by different authors, the common couples' children (Halford, Kelly, & Markman,
emphasis is on altering how partners respond to 1997). These individual problems often result
behaviors of their spouses which they dislike. from the prolonged effects of marital distress,
Christensen et al. (1995) describe the goal of this and make marital therapy less effective (Halford
process as promoting acceptance, which they & Bouma, 1997). Furthermore, patterns of
define behaviorally as the reduction of attempts dysfunctional marital interaction typically be-
to get the other person to change. In essence, come entrenched over time and resistant to
there is an attempt to balance a combination of change (Markman, Floyd, Stanley, & Storaasli,
1988; Raush, Barry, Hertel, & Swain, 1974). both partners in couples therapy are using the
Eventually there is erosion of any positive affect therapy as a way of exiting the relationshipÐ
toward the spouse, which is predictive of very leaving the hurt spouse on the therapist's
poor response to couples therapy (Hahlweg, doorstep. Some marital therapists describe
Schindler, Revenstorf, & Brengelmann, 1984). how a spouse who is interested in leaving the
Approximately 25±30% of couples show no relationship often brings in the other spouse
measurable improvement with CBCT, and as with the hope that the therapist will help wean
many as a further 30% improve somewhat from the more committed spouse from the marriage
therapy but still remain significantly maritally and ease the break-up of the relationship.
distressed after treatment (Bray & Jouriles, In a survey of therapists conducted with
1995; Halford et al., 1993; Jacobson, 1989; practitioners in Colorado in the US (Stanley,
Jacobson et al., 1984). Even among those Lobitz, & Markman, 1989), couples' therapists
couples who initially respond well to CBCT, were asked to indicate the percentage of couples
there is substantial relapse toward marital who were significantly improved or not im-
distress over the next few years (Jacobson, proved, how many of the couples seen in the
Schmaling, & Holtzworth-Munroe, 1987; Sny- practice were still together, and how many
der, Mangrum, & Wills, 1993; Snyder et al., decided to end their relationship. The results
1991a). The consistent finding is that the longer indicated that about 33% of the relationships
couples have been maritally distressed, and the ended in separation or divorce. Interestingly,
more severe their relationship dissatisfaction, the therapists rated 80% of these relationships
the poorer their response to marital therapy that ended in divorce as a successful outcome.
(Whisman & Snyder, 1997). The Consumer Reports survey suggests that this
The effectiveness of CBCT relative to other 80% probably did not rate the therapy as a
approaches to couples therapy is unclear. There success from their own perspective (Seligman,
are relatively few studies which compare 1995). Consumer satisfaction with couples
approaches to couples therapy (Snyder et al., therapy may be low because people unrealisti-
1991a). One study compared insight-oriented cally expect therapy to persuade their partners
and behavioral marital therapies. The findings to stay with them.
were that each treatment was effective, with few
significant differences in effects of the treat-
ments in the short term (Snyder & Wills, 1989). 6.28.5.5 Couples Therapy and Psychological
At four-year follow-up the insight-oriented Disorder
therapy was associated with lower rates of
divorce and higher rated marital satisfaction Couples therapy can be useful in the treat-
than the behavioral marital therapy (Snyder ment of individual psychological disorders,
et al., 1991a). However, this study has been the either as the entire treatment or as an adjunct
source of considerable controversy (Jacobson, to individual treatment. More specifically, there
1991; Snyder et al., 1991b). A major criticism of have been a number of studies evaluating
the study was that the so-called insight-oriented couples therapy and its effects on depression
therapy was not really psychodynamic in and alcohol abuse. In this section we evaluate
approach, but rather represented state of the this evidence.
art CBCT (Jacobson, 1991). As noted previously, people with co-existing
An important index of the value of couples marital problems and depression often do not
therapy is the satisfaction of clients with the respond well to traditional individual therapies
service they receive in that therapy. The for depression. Beach and O'Leary (1986) and
magazine Consumer Reports, which is very Jacobson, Dabson, Fruzetti, Schmaling, and
widely read in the US, has its readers complete Salusky (1991) showed that CBCT was effective
a survey every year. In one survey they asked in reducing both marital distress and depression
about satisfaction with psychotherapy, includ- where wives were depressed and the couples
ing couples therapy. The results were very were maritally distressed. Individual cognitive
positive in terms of the effects of psychotherapy therapy also was somewhat effective with these
from the consumers' point of view. However, clients, but not as effective as CBCT (Beach &
consumers expressed less satisfaction with O'Leary, 1986; Jacobson et al., 1991). Of
couples' counseling than any other form of particular interest was Jacobson's finding that,
therapy. From one perspective, this makes the while both CBCT and cognitive therapy were
field of couples' counseling look ineffective. helpful, adding cognitive therapy to CBCT did
However, when one thinks about the goals of not enhance outcome. In Jacobson's study the
couples therapy, it actually makes sense that treatment conditions were matched for total
there will be less satisfaction from the con- hours of therapy contact. As a consequence the
sumers' point of view. Often one or sometimes combined condition got less CBCT than the
Couples Therapy 637
CBCT alone condition, and this may explain many people who abuse alcohol to accept
why the combined treatment condition did not treatment. Partners of male problem drinkers
do as well. often present to treatment agencies reporting
The Jacobson et al. (1991) study highlights that their partners refuse to seek treatment
that couples therapy should not be used for all (Halford & Osgarby, 1993). The frequent
presentation for depression by married clients. unwillingness of the person abusing alcohol to
For depressed clients where there was no accept help, with consequent strains on the
marital distress, individual cognitive therapy relationship and individual distress, have
was superior to couples therapy in its effect on prompted the development of therapies to assist
depression. Even when relationship problems the spouses of heavy drinkers. For example,
and depression coexist there is a need to make Sisson and Azrin (1986) and Thomas and Ager
careful judgments as to when couples therapy is (1993) both developed therapies aiming to help
most helpful. In couples where the individual clients reduce the negative impacts of their
depression is severe, the marital problems partner's drinking. Both these programs were
postdated the onset of depression, and neither aimed at teaching women to manage stress
partner attributes the cause of the depression to associated with their husbands' drinking and to
the marital problems, then marital therapy encourage the men to seek individual therapy
seems less effective than individual therapy (Sisson & Azrin, 1986; Thomas & Ager, 1993).
(Jacobson et al., 1991). On the other hand, These programs do assist the women to reduce
where the marital problems antedate the their individual distress, and there is some
depression, the marital problems are severe, evidence that these approaches can increase the
and the source of the depression is attributed by chance of the male drinker presenting for
at least one of the partners to the marital individual treatment (Halford, Price, Bouma,
problems, then marital therapy seems to be the Kelly, & Young, 1998; Sisson & Azrin, 1986;
treatment of choice (Jacobson et al., 1991). Thomas & Ager, 1993).
There is a large body of literature attesting to Some programs for the wives of male problem
the value of various forms of couples therapy in drinkers were also aimed at helping the women
the treatment of alcohol problems. The best to influence the men to reduce drinking. For
established approach is the use of CBCT to example, Sisson and Azrin (1986) described
complement individual therapy in the treatment helping women to identify high-risk settings for
of alcohol abuse. In the case of people with heavy problem drinking, and suggested that wives
dependence on alcohol, there has been successful schedule activities incompatible with drinking
use of conjoint contracting to promote use of for high-risk times. Partners have also been
antebuse (an oral drug which induces severe encouraged to praise sobriety, and not to
illness if alcohol is consumed) to establish inadvertently reduce the negative consequences
abstinence (O'Farrell & Bayog, 1986). Once of drinking (e.g., by refusing to ring your
sobriety is established, conjoint couples therapy partner's supervisor to say your partner is sick
when used in combination with ongoing use of when he really has a hangover). Similar
antabuse promotes both improvements in strategies were used by Halford et al. (1998).
relationship satisfaction and enhanced main- The only systematic evaluation of this approach
tenance of drinking control (O'Farrell, Cutter, was in the Halford study, which found that these
Choquette, Floyd, & Bayog, 1992; O'Farrell, strategies had little impact upon the drinker's
Cutter, & Floyd, 1985). When CBCT is alcohol consumption. The degree to which
combined with relapse prevention training, there women actually implemented the suggested
is even better maintenance of reduced alcohol strategies was not evaluated, so it is unclear if
consumption (O'Farrell, Choquette, Cutter, women were unconvinced to implement the
Brown, & McCourt, 1993). Furthermore, there suggestions or if women changing these beha-
is also a substantial reduction in the prevalence viors had little effect on the men's drinking.
of marital violence after CBCT, at least in those In summary, CBCT is a well-established
couples with mild to moderate severity of treatment for relationship problems which has
violence (O'Farrell & Murphy, 1995). demonstrated efficacy. CBCT is also very useful
There are two significant limitations on the in the treatment of depression and alcohol
evidence of the impact of couples treatments for problems of adults in committed relationships.
problem drinking. First, all successful trials However, common to all applications of CBCT
have used antabuse, and the effectiveness of and other approaches to couples therapy is a
CBCT without antabuse is unclear. Second, up substantial input of time from therapists and
to 50% of men in alcohol treatment refuse offers couples. As described in the research and
of couples-based treatment (O'Farrell, Kleinke, clinical literature, couples therapy typically
Thompson, & Cutter, 1986). This may be involves anything from 12 to 30 sessions of
associated with more general reluctance of conjoint therapy (e.g., Baucom & Epstein, 1990;
Greenberg & Johnson, 1988; Snyder et al., marriage (e.g., Markman, 1981; Halford et al.,
1991a; Weiss & Halford, 1995). The time 1994) and with married couples not experien-
commitment and costs involved in all these cing relationship distress (e.g., Guerney, 1977;
approaches probably are a major disincentive to Miller et al., 1975).
couples to seek assistance; only a small minority Skills training prevention programs do
of distressed couples ever seek out therapy increase couples' communication and problem-
(Sanders, 1995; Wolcott & Glazer, 1989). Thus, solving skills (Hahlweg & Markman, 1988;
even if CBCT were optimally effective for those Markman et al., 1988; Miller, Nunnally, &
who present for therapy, it would have modest Wackman, 1975). In their meta-analysis of
impact on the community prevalence of re- controlled trials of such interventions, Hahlweg
lationship problems. This has led to attempts to and Markman (1988) found an effect size of 1.51
prevent relationship problems. on communication skills. Given that an effect
size of 0.8 is generally considered a large effect
size, this is a very impressive result. Couples in
6.28.6 PREVENTION OF RELATIONSHIP prevention trials are, by definition, currently
PROBLEMS satisfied with their relationships. Consequently,
6.28.6.1 Prevention and Early Intervention it is unlikely that prevention programs could
produce large, immediate increases in relation-
Programs to prevent relationship problems ship satisfaction above the pre-existing high
vary greatly along several dimensions, including levels. Consistent with this interpretation,
the phase of the relationship at which they are Hahlweg and Markman (1988) report a mean
targeted, the settings in which they are offered, effect size across seven premarital programs of
the number and duration of sessions, the level of 0.51 on relationship satisfaction, which is still a
training of the service providers, the extent to moderate size effect.
which didactic vs. experiential forms of learning Over time many couples show declines in
are emphasized, and the amount of group vs. relationship satisfaction (Markman & Hahl-
dyadic interaction that occurs (Guerney, Guer- weg, 1993), and the real test of prevention
ney, & Cooney, 1985; Levant, 1986; Van programs' effectiveness is whether the onset of
Widenfelt, Markman, Guerney, Behrens, & relationship problems can be prevented. A
Hosman, 1997). Existing programs can be significant methodological problem associated
usefully classified into two broad categories: with evaluating prevention programs is devising
(i) counseling and educational programs (e.g., appropriate comparison conditions for long-
Mace & Mace, 1976; Rutledge, 1968), and (ii) term controlled trials. If couples are randomly
skill acquisition and cognitive restructuring assigned to a no-intervention control when they
programs (e.g., Guerney, 1977; Markman, desire intervention, they may seek intervention
1984; Markman, Floyd, Stanley, & Lewis, outside the study. On the other hand, failure to
1986). Programs are based on a wide range of randomly assign to conditions can make
theoretical perspectives including social learning interpretation of results difficult. Perhaps
theory, Rogerian theory, and systems theory because of these difficulties few studies have
(Bradbury & Fincham, 1990). Regardless of assessed long-term outcome. A survey of 85
theoretical orientation, all programs include couple and family prevention and enrichment
efforts aimed at improving communication and studies found that only 40% included follow-up
problem-solving, negotiation of roles and re- measures at some point after post-test (mean
sponsibilities, clarification of values and expec- follow-up was 12 weeks), with the longest
tations, sexuality and intimacy, developmental follow-up assessment occurring at 12 months
changes and transitions (e.g., parenting), and (Giblin, Sprenkle, & Sheehan, 1985). Only
awareness of relationship dynamics. Markman and co-workers (e.g., Markman
The rationale for skills-based prevention of et al., 1988; Markman, Renick, Floyd, Stanley,
relationship problems is that acquisition of & Clements, 1993) have reported follow-up data
crucial relationship competencies are presumed beyond two years.
to prevent problems. As noted earlier, research Markman and co-workers found that skills-
has identified these crucial competencies to based marital distress prevention programs
include constructive communication and reduce marital violence (Markman et al.,
problem-solving skills, management of negative 1993), and the prevalence of marital separation
affect and conflict, realistic relationship beliefs and divorce over the first 5±10 years of marriage
and expectations, and promotion of positive (Markman et al., 1993). However, these series of
behavior exchange (Markman, 1984; Notarius studies have a methodological problem. Sub-
& Vanzetti, 1984). Programs designed to jects initially were recruited for a long-term
improve couples' abilities in these areas have follow-up study of marriage, and subsequently
been conducted both with couples planning randomly assigned subjects to matched groups
Prevention of Relationship Problems 639
to be offered, or not offered, an intervention. the leader avoids responsibility for helping the
Sixty percent of couples offered the relationship partners to determine goals. Rather, the role of
preparation program declined to participate. the leader is to help both partners to accurately
The two treatment conditions consist of those self-evaluate their current communication and
who accepted the program and their matched to develop specific, self-selected goals for
controls. As the treatment group were self- enhancing communication.
selected for agreeing to participate in the Another exercise often used in communica-
program, and the matched controls were not tion skills training is to ask the couple to have a
offered the program, there is confound between discussion at home which they audiotape. At the
the conditions of self-selection. end of the discussion both partners self-evaluate
Despite the limitations of the existing re- their communication skills, formulate self-
search, it is clear that skills-based prevention change goals, and then repeat the conversation
programs do modify aspects of couples' adap- building on the selected communication skills.
tive processes which are identified risk factors Each partner then evaluates the impact of
for relationship problems. The long-term main- changing communication skills on the commu-
tenance of these behavioral changes needs nication process. This procedure allows the
further investigation, as do the long-term effects partners to directly test the hypothesis that
of these interventions on relationship problems, changing their communication behaviors in a
but preliminary results are encouraging. particular way will enhance the relationship
communication process. It also has the partners
6.28.6.2 Content of Prevention Programs practice active self-correction of ineffective
communication attempts.
The content covered in skills-based preven- Communication tasks that we recommend in
tion programs can be usefully considered as relationship enhancement initially focus on
falling into six modules: (i) behavior exchange nonconflictual topics. For example, we empha-
and positive intimacy enhancement, (ii) com- size to couples the importance of discussing day-
munication skills enhancement, (iii) manage- to-day occurrences on a regular basis, so as to
ment of conflict and negative affect, (iv) sexual keep informed and interested in the experiences
enrichment, (v) gender role flexibility, and (vi) of your partner. Consequently, we usually ask
adaption to life transitions and maintenance of couples to have a series of discussions about
relationship satisfaction. We will consider each what each does during the time they are apart.
of these in turn. We also ask the couple to address ways in which
Behavior exchange and positive intimacy they can support and show interest in each
enhancement procedures have been adapted other's interests. This support might be in work,
from those used in couples therapy. As for parenting, household chores, or in particular
therapy, the emphasis is on each partner self- interests or hobbies. The relevant communica-
selecting behavior change goals which enhance tion task is for one partner to initiate a
relationship functioning. In prevention pro- conversation with their spouse about the
grams this is often much easier to achieve than spouse's interests and needs. Both partners
in therapy. In therapy, couple's negative feelings are asked to identify ways in which they might
toward each other and possible ambivalence be more supportive.
about the relationship often inhibit partners Conflict management is another important
from making relationship enhancing efforts. element of prevention programs. Once couples
Prevention program couples, by definition, have a reasonable level of communication skills,
have positive feelings about their partner and they can then use these communication skills to
relationship. handle difficult conflictual issues. In discussion
Communication skills training involves in- of conflict management we describe the differ-
dividuals self-selecting goals for enhancing their ent settings in which conflictual topics may be
own communication from an array of available discussed, and the fact that there are some
skills and self-evaluating their own commu- settings in which it is easier to have a productive
nication. This can be done by asking the couple discussion than others. Couples are asked to
to have a discussion. Immediately after the consider the times, places, and circumstances in
discussion both partners are asked to self-assess which they could most productively talk about
their communication using a checklist of topics which are difficult. Also couples are
potentially helpful communication behaviors educated about the common maladaptive
set out on the form in Table 4. After completing patterns in interaction around conflictual
the form, partners self-identify specific com- topics, such as the demand-withdraw and
munication behaviors that each would like to mutual avoidance patterns. Couples self-select
increase in their repertoire in order to enhance goals which will help them to avoid those
their communication. This does not mean that unhelpful patterns of interaction.
Table 4 Communication skills self-evaluation form.
Name: Date:
The aim of this form is for you to identify your strengths and weaknesses in communication and to specify
goals for improvement. Rate each of the skills below using this code:
0 Ð Very poor use of skill

1 Ð Unsatisfactory use of skill
2 Ð Satisfactory use of skill, but room for improvement
3 Ð Good use of skill
N/A Ð Not applicable
Skill 0 1 2 3 N/A
Specific descriptors
Self-disclosure
Clear expression of positives
Assertive expression of negatives
Attending to partner
Minimal encouragers
Reserving judgement
Asking questions
Summarizing content
Paraphrasing feelings
Self-identified strengths in communication:
Self-identified weaknesses in communication:
Another useful notion in relationship prep- that is troubling them at any time. Other couples
aration programs is the idea of relationship may feel that there is some responsibility to raise
rules for managing conflict. Relationship rules difficult issues at times and in places which
refer to the implicit assumptions and processes maximize the chance of productive discussion.
which couples develop for handling conflict. Table 5 lists some common relationship rules
For exmple, some couples may believe that that couples may apply to managing conflict.
either partner should be able to raise any issue Through discussion and negotiation couples
Prevention of Relationship Problems 641
can be asked to agree on relationship rules that specific behavior changes they wish to make in
increase their chance of managing conflict order to become more gender role flexible. For
effectively. example, males may set themselves the target of
Sexual enrichment is also an important learning to cook better, and women to learn how
element of many prevention programs. We to maintain a car. An additional rationale for
make use of the widely available video tape The this process is that often the domestic respon-
lovers guide. We would play this to couples, ask sibilities in families fall primarily on women, and
them to talk about their general reactions as a this is a major source of relationship dissatisfac-
group, and then have the couples talk together tion for women. We point out to our male
in privacy about any goals they may wish to set participants that women initiate approximately
in order to enhance their sexual experience. The three-quarter of all divorce proceedings (Wol-
video that we show is very sexually explicit, cott & Glezer, 1989). If men want to remain in
demonstrating ways in which one can enhance happy relationships, then they need to ensure
sensual and sexual pleasure, and identifies and that they are domestically competent to con-
describes some common sexual difficulties. We tribute to the household.
find that showing this tape is useful in helping In relationship preparation and enhancement
couples to talk intimately about their desires to programs it is important that couples prepare
enhance their sexual relationship. themselves for future changes in their relation-
Gender role flexibility is another element of ship likely to result from major life transitions
some prevention programs. Gender role flex- (Hahlweg & Markman, 1993). In one such
ibility refers to each partner taking some exercise couples complete an adapted form of
responsibility for a wide range of relationship the life change event scale and are asked to rate
maintaining activities, and transcending very the likelihood of these events occurring in the
rigid or traditional gender-based definitions of next one or two years and the probability that if
responsibilities. The notion of gender role those events occur they might have a negative
flexibility can be introduced by asking both effect on their relationship. For example,
partners to identify which of a range of different couples are asked to identify the ways in which
behaviors, which potentially can be stereotyped events such as birth of a child, loss of a job, or a
as belonging to a woman or a man, they take change of work circumstances might impact on
responsibility for within the relationship. The their relationship. Partners are asked to self-
potential value of being flexible in gender roles is select goals that they believe would help them
in helping the couple adapt to changing life adapt in a relationship-maintaining way to these
circumstances. For example, if both partners are life transitions. For example, a number of
able to earn an income, then the couple can adapt couples have identified that they may have
better if one person has difficulty obtaining reduced opportunities for having time together
work. Partners can be helped to self-identify as a couple once they have children. They have
Table 5 Suggested ground rules for handling conflict.
1. We can bring up issues at any time, but the ªlistenerº can say
ªthis is not a good timeº If listener does not want to talk at
that time, he or she takes responsibility for setting up a time
to talk in the near future (you need to decide on how ªthe
near futureº is defined) Yes No
2. When conflict is escalating we will call a ªstop actionº and (i)
try it again, using the speaker/listener technique, (ii) agree
to talk later at a specified time about the issue, using the
speaker/listener technique Yes No
3. When we are having trouble communicating we will
ªengagerº the speaker/listener technique Yes No
4. When using the speaker/listener technique, we will completely
separate problem-discussion from problem-solution Yes No
5. We will have weekly ªcouple meetingsº (you should set up a
time now) Yes No
6. We will state when we have a problem, if we want to negotiate
a relationship, or just solve the immediate problem Yes No
Source: Markman, Stanley, and Blumberg (1995).

then set individual goals, such as ensuring child positive shared experiences. Other important
minding is available or that they cultivate contributors to relationship problems are en-
activities they can do at home, which increase during vulnerabilities of the partners, such as
the chance of having mutual shared enjoyable individual psychological disorders and stressful
activities when they have young children. life events. Couples lacking robust adaptive
In Table 6 we have set out the typical content couple processes are likely to develop relation-
of each of five 2 hour group sessions of a ship problems when challenged by major life
relationship preparation program. This is not a transitions and stressful events.
rigid schedule that must be followed, but rather Cognitive-behavioral couples therapy is a
a schematic representation about how a group well-established and effective means of helping
might work. Sessions can be combined and many couples with relationship problems.
homework resequenced to cover the same Effective couples therapy uses the assessment
content in a full day, with one or two follow- process to help partners build a shared and
up sessions. constructive model of their relationship pro-
blems, and to define individual action that can
improve the relationship. Therapy itself assists
6.28.7 CONCLUSIONS partners to self-direct a change process focused
on enhancing positive exchange between part-
Relationship difficulties are very common, ners, improving communication, and control-
and have a huge impact on adults and their ling destructive conflict. Adaptions of these
offspring. The most common relationship procedures have been used successfully to teach
problems are lack of relationship satisfaction, currently satisfied couples to enhance their
ambivalence about the future of the relation- relationship and to prevent future relationship
ship, and problems in the adaptive interactional problems.
processes between partners. In the domain of
the adaptive processes between the partners the
most important factors contributing to relation- ACKNOWLEDGMENTS
ship problems are poor communication, poor
management of negative affect and conflict, Preparation of this chapter was supported by
unrealistic beliefs and expectations, and lack of an Australian Research Council Grant on
Table 6 Overview of typical content in a five session premarital skills training program.
Session Detail of content
1 Introduction to group members; explain rationale for self-directed, skills training focused group
program; identification of key behavioral domains promoting relationship intimacy; self-directed
intimacy enhancement through self-directed goal setting and definition of homework task of
behavior change; identification and modeling of key communication skills to enhance intimacy
2 Review of intimacy enhancement behavioral homework tasks; self-directed selection of further
behavior change goals; review of key communication skills; guided self-evaluation of current
communication skills; self-directed selection of communication enhancement goals and practice of
implementation of those skills; self-directed goal setting and definition of homework task to
enhance communication
3 Review of communication homework tasks, and self-directed further goals selection and definition of
further homework task; introduction to the concept of the patterns of conflict and effective conflict
management; negotiation with partner about relationship rules for managing conflict; self-directed
goal setting for effective management of conflict; introduction to the concept of flexible gender
roles, couple review of current gender roles, self-directed goal setting for future gender role
flexibility
4 Review of communication homework task; review of the role of sexuality in relationship intimacy;
couple discussion and goal setting to enhance sexual intimacy; introduction to the concept of
partner support, self-directed goal setting to enhance partner support; self-directed definition of
homework tasks to implement selected goals in areas of sexuality or partner support
5 Review of homework tasks; self-directed selection of any further goals to enhance relationship
functioning; introduction of issue of maintenance of relationship functioning; self-directed
identification of future life events impacting upon relationship; planning to promote relationship
adaptation to predictable life events
Closure
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6.29
Eating Disorders
ANITA JANSEN
Universiteit Maastricht, The Netherlands

6.29.2 ANOREXIA NERVOSA 650
6.29.3 BULIMIA NERVOSA 651
6.29.4 OBESITY AND BINGE EATING DISORDER 652
6.29.5 ATYPICAL EATING DISORDERS 653
6.29.6 DIFFERENTIAL DIAGNOSES AND COMORBIDITY 653
6.29.6.1 Differential Diagnoses 653
6.29.7 PREVALENCE AND PROGRESS 654
6.29.8 ETIOLOGY 655
6.29.8.1 Genetics 655
6.29.8.2 Childhood Sexual Abuse 656
6.29.8.3 Dieting for the Perfect Figure 656
6.29.8.4 Serotonin Depletion 657
6.29.8.5 The Learned Nature of Binge Eating 659
6.29.8.6 Dysfunctional Cognitions 659
6.29.9 TREATMENT 661
6.29.9.1 Anorexia Nervosa 661
6.29.9.2 Bulimia Nervosa 662
6.29.9.3 Obesity and Binge Eating Disorder 663
6.29.9.4 Predictors of Treatment Outcome 663
6.29.10 IN CONCLUSION 663
6.29.1 INTRODUCTION This chapter discusses eating disorders.

Eating disorders differ from the problems
Nowadays, more than half of all women diet mentioned above in the frequency and ser-
because they believe they are too fat (e.g., Agras, iousness of the symptoms and the extent to
1990). In the late 1970s, one in every five of a which they interfere with the individual's
sample of British women binged once a month, functioning. With an eating disorder, the
and 10% of these women regurgitated after symptoms are much more serious and frequent
bingeing in order to get the quantity of food than with an eating problem. Unlike an eating
eaten out of the system as quickly as possible problem, an eating disorder is often dysfunc-
(Wardle, 1980). Eating behaviors of this type tional: the patient suffers from it to an extent
can be problematic, but they are seen so that it is virtually impossible to function
frequently that they can no longer justifiably normally. This is not always evident to others;
be categorized as ªabnormal.º the eating disorder bulimia nervosa, for
649
650 Eating Disorders
example, can be concealed by sufferers for The group of anorexia nervosa patients can
many years. be divided into two subgroups: the binge/
The eating disorders anorexia nervosa and purging type and the restricting type (American
bulimia nervosa, as well as atypical variations of Psychiatric Association [APA] 1994). Purging
these disorders and the recently identified binge refers to behavior oriented towards getting the
eating disorder, are discussed in the present food out of the body as quickly as possible: self-
chapter. Because eating disorders are primarily induced vomiting and the use of laxatives and
seen among women, patients will be referred to diuretics (substances that stimulate the excre-
as women. After a clinical description of the tion of fluids: ªpee pillsº). Dieting, fasting, and
eating disorders, the diagnostic features, differ- sports activities are not considered purging
ential diagnoses, comorbidity and prevalence behavior. An average of nine months after
are discussed. Next, empirically validated anorexia nervosa commences, about half of the
theories of the origin and maintenance of eating patients start to suffer from uncontrollable
disorders are considered. A final section bingeing and purging behavior (Polivy &
discusses the effectiveness of the various treat- Herman, 1985; Wardle & Beinart, 1981).
ments currently available. Purgers often stimulate the vomiting reflex by
sticking a finger, toothbrush, or other oblong
object into the desired position in the throat.
6.29.2 ANOREXIA NERVOSA After some time, some patients can stimulate
this reflex simply by exerting a small amount of
The characteristic of a patient with anorexia pressure on the stomach under the ribs.
nervosa is that she continually assumes that she Vomiting is then more or less ªautomatic.º
is too fat. This conviction fuels an intense drive Some chronic vomiters have a hard spot or callus
to be thinner, sometimes referred to as a on the back of the hand or under the ribs. This
relentless pursuit of thinness. The fervent desire callus results from the hand rubbing along the
to lose weight continually dominates the teeth or from exerting pressure on the stomach.
patient's thoughts, feelings, and behavior The use of laxatives is not as effective as the
(Garfinkel, 1995). She eats only low-calorie patient often believes. Laxatives rinse food
food and exerts an enormous amount of through the intestines at an accelerated speed.
physical effort, resulting in a loss of weight. This rapid journey through the digestive track
Sleeping problems and depression can result can prevent complete absorption of the nu-
from malnutrition. It is striking that neither the trients, as a result of which somewhat less
idea of being too fat nor the fear of gaining energy (kilocalories) is absorbed. The weight
weight disappear as the weight loss continues. loss achieved in this manner, however, is small
On the contrary, as weight decreases, the fear of and short-lived because the laxatives primarily
becoming fat intensifies. Another striking stimulate the excretion of fluids. The weight lost
aspect is that the patient usually denies the is regained after drinking a few glasses of fluids.
seriousness of the loss of weight. A paradoxical effect of the long-term use of
Incessant attempts to lose an extreme amount laxatives is that constipation occurs because of
of weight, and the belief among these under- the reduced or complete loss of activity of the
weight patients that they are still too fat, intestines.
resulted in recent decades in the suspicion by Patients of the other, restricting type do not
numerous specialists and researchers that a suffer from binges. These patients continually
distorted perception of the body is characteristic restrict their intake of food and therefore do not
of patients with anorexia nervosa. Patients with turn as easily to the purging measures explained
anorexia nervosa were presumed to overesti- above. Which factors determine when and why
mate the size of their body. However, this a patient changes from a restricting type to a
clinical impression could not be irrefutably purging type with binges is unknown. The two
confirmed. Researchers asked patients, for groups do, however, differ in a number of other
example, if they could estimate the size of their ways: on average, the bingeing/purging type has
body while viewing themselves on a video a higher weight before the anorexia nervosa
monitor. By turning knobs they could show on started and suffers more often from disorders
the screen how big they thought they were. It involving controlling impulses, excessive use of
was learned that some patients with anorexia alcohol or drugs, mood disorders, and person-
nervosa overestimate the size of their body more ality disorders (Garfinkel, 1995).
than others, while other patients with anorexia Malnutrition and purging behavior have
nervosa did not. Moreover, it was determined medical consequences. The menstrual cycle is
that people without an eating disorder also usually interrupted, and when underweight be-
often overestimate their size (Garfinkel, 1995; comes extreme the menses cease. The extremities
Smeets, Smit, Panhuysen, & Ingleby, 1997). (fingers, toes) are cold and turn purple-blue (this
Bulimia Nervosa 651
is referred to as cyanosis), the body temperature as a dream and cannot remember the details.
is low (hypothermia), which can result in a After bingeing, in the very short term, the binge
downy layer of hair growing on the body improves affect, but very soon thereafter (often
(lanugo), the blood pressure is low (hypoten- even before the end of the binge) the subject feels
sion), and the heartbeat is slow (often lower than guilty and self-disgusted. The patient is afraid of
60 beats per minute: in medical terms brady- gaining weight and seeks refuge in the compen-
cardia). The metabolism is also often slow. The sational behavior described above: purging and
physical consequences of malnutrition often dieting.
disappear once the eating pattern and weight The chaotic eating pattern (alternating be-
have returned, but this can take some time. tween much and little) results from extreme
The diagnostic criteria for anorexia nervosa worry about the figure, appearance, and weight.
according to the Diagnostic and statistical Like patients with anorexia nervosa, despite the
manual of mental disorders (4th edn., DSM- fact that their weight is often normal, patients
IV) are listed in Table 1. with bulimia nervosa believe they are heavy,
slow, and fat (Phelan, 1987). These irrational
ideas about their figure and weight determine to
6.29.3 BULIMIA NERVOSA a significant degree their self-esteem, which is
often low.
A chaotic eating pattern, weight-control Patients with bulimia nervosa also have
measures, and irrational ideas about one's irrational cognitions about things other than
figure, appearance, and weight are character- their body shape and weight. Their ideas about
istic of the eating disorder bulimia nervosa food and eating are also dysfunctional
(APA, 1994). Normally, periods of sparse eating (Dritschel, Williams, & Cooper, 1991). Every-
alternate with binge eating episodes (bulimia thing that is edible is either ªgoodº or ªbad.º
literally means ªas hungry as an oxº). During a Good food is food that has a low amount of
binge, in an uninterrupted period of time an kilocalories (e.g., skimmed yogurt, bouillon,
amount of food is consumed that is consider- and lettuce); bad food is food with a high
ably larger than most people would normally amount of calories, and is ªforbiddenº (e.g.,
eat in the same period of time. Typical is the chocolate, pizza, and fried meat). Eating a bit of
subjective feeling of loss of control over eating: forbidden food is ªcompletelyº bad. This
during the binge, the patient feels as if she can no dichotomous (black-and-white) thinking style
longer stop or control what or how much she is an invitation to failure: the stricter the rules
eats (Fairburn & Wilson, 1993). The binge can they apply to themselves, the more likely the
be induced by a variety of stimuli: fluctuating rules are to be broken.
moods (e.g., depression, fear, euphoria), the Bulimia nervosa, like anorexia nervosa, is
breaking of idiosyncratic diet rules, for exam- often accompanied by medical complaints that
ple, by eating ªforbiddenº food (i.e., food rich in result from the binges, vomiting, fasting, and
calories), and a craving for food stimulated by use of laxatives and diuretics. Most of these
the smell of palatable food (Jansen & van den complaints are reversible and disappear as soon
Hout, 1991). Some patients describe a type of as the eating behavior has normalized. Some,
dissociative amnesia: they experience their binge however, are life threatening. When vomiting
Table 1 DSM-IV diagnostic criteria for 307.1 anorexia nervosa.
A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss
leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight
gain during period of growth, leading to body weight less than 85% of that expected)
B. Intense fear of gaining weight or becoming fat, even though underweight
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight
or shape on self-evaluation, or denial of the seriousness of the current low body weight
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles (a
woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen,
administration)
Specify type:
Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-
eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas)
Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in
binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
and using laxatives and diuretics, the patient (1.68)2 = 22.3. A BMI between 20 and 25
loses a significant amount of fluids. This shows a healthy weight. The more a BMI drops
dehydration may result in thirst, dry skin, below 20, the more severe the underweight is,
dizziness when rising from a sitting or hor- and, vice versa, the more the BMI rises above
izontal position, light-headedness, and fainting. 25, the more severe the overweight (see Table 3).
Chronic purging can also result in serious Levels of BMI greater than 30 are usually taken
disorders of the electrolyte balance. Electrolytes to indicate obesity.
(the most important of which are sodium, In most cases, obesity develops in the absence
potassium, and chloride) are called just that of any medical disease (Foster, 1992), but it is a
because they are responsible for the transmis- risk factor for a range of major health hazards,
sion of electrical signals between the cells in our including cardiovascular diseases, hypertension,
body. They play an important role in metabolic diabetes, stroke, hypercholesterolemia, gall-
processes and ensure that the nerve and muscle bladder diseases, and osteoarthritis (Wardle,
cells function properly. As a result of purging, a 1995; Willett & Manson, 1995). Statistics from
considerable quantity of electrolytes, in parti- life insurance companies show a significant
cular sodium and potassium, are excreted. increase of morbidity and mortality when the
Serious shortages can be life threatening BMI rises above 30. The health consequences are
because the heart muscle is weakened and more serious for the obese with fat around the
receives insufficient impulses to compress and waist (the ªappleº) than for obese subjects with
then relax. A simple blood test can indicate fat around the hips and thighs (the ªpearº).
whether the electrolyte levels are abnormal. Stigmatization, prejudice, and discrimination
The DSM-IV criteria for bulimia nervosa are of the obese, for example, in relation to
listed in Table 2. acceptance for a job, makes obesity a psycho-
logical problem as well. Obesity is considered
unattractive in Western cultures, leading to
6.29.4 OBESITY AND BINGE EATING
negative self-images and even self-hate in obese
DISORDER
persons, especially women (Foster, 1992;
Obesity refers to an excess of body fat. Stunkard & Wadden, 1992). Children as young
Because body weight and body fat are highly as six years of age describe silhouettes of obese
correlated, overweight is often used as a proxy children as ªlazy, dirty, stupid, ugly, cheats, and
for obesity (Brownell, 1995; Wardle, 1995). To lies,º and they rate children with a variety of
determine whether someone's weight is in or disabilities as more attractive than the obese
outside the normal range, the body mass index children (Rodin, Silberstein, & Striegel-Moore,
(BMI) is generally used. The BMI refers to the 1984). Low self-esteem, feelings of anxiety,
ratio of height and weight; it is calculated by depression, and guilt are frequently seen in the
dividing body weight (in kilograms) by height2 seriously obese (Stunkard & Wadden, 1992).
(in meters). For example, the BMI of a subject Following the definitions of DSM-IV, obesity
weighing 63 kg and 1.68 m tall is: 63/ is not defined as an eating disorder or even as a
Table 2 DSM diagnostic criteria for 307.51 bulimia nervosa.
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
(1) eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely
larger than most people would eat during a similar period of time and under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating)
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced
vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a
week for 3 months
D. Self-evaluation is unduly influenced by body shape and weight
E. The disturbance does not occur exclusively during episodes of anorexia nervosa
Specify type:
Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced
vomiting or the misuse of laxatives, diuretics, or enemas
Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate
compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-
induced
vomiting or the misuse of laxatives, diuretics, or enemas
Differential Diagnoses and Comorbidity 653
Table 3 Body Mass Index. accounted for by binge eating; it is the severity
of binge eating and not the severity of obesity
BMI Weight category which is correlated with the indices of psycho-
pathology (Castonguay et al., 1995). Note,
518 Severe underweight however, that the obese nonpurging binge eaters
18±20 Underweight
20±25 Normal weight
show less psychopathology than the purging
25±27 Slightly overweight bingers, i.e. subjects with bulimia nervosa.
27±30 Overweight
430 Obesity
30±35 Mild obesity 6.29.5 ATYPICAL EATING DISORDERS
35±40 Moderate obesity
440 Morbid or severe obesity About one-third of the patients who pre-
sented in England for the treatment of an eating
Body Mass Index (BMI) = weight/height2; kg/m2.
disorder failed to meet the diagnostic criteria for
anorexia or bulimia nervosa (Fairburn &
Walsh, 1995). They normally have an atypical
mental disorder. Until recently, obesity has eating disorder or, in DSM-IV terms, an eating
generally been studied by doctors and biologists, disorder ªnot otherwise specifiedº (APA, 1994).
whereas eating disorders have always been These are people who, for example, meet all of
within the scope of psychologists and psychia- the criteria for anorexia nervosa except that they
trists. However, in the last few years, interest in still have a regular menstrual cycle, or they have
obesity among psychologists and psychiatrists lost a considerable amount of weight, but the
has been growing. One of the main reasons for weight is not low enough. A patient may also
this renewed interest is the recognition of meet all of the criteria for bulimia nervosa
increased psychopathology in some obese except that the binges do not occur frequently
people. enough.
This subgroup of the obese population
frequently overeat in a way which could be
described as bingeing. Some of these obese 6.29.6 DIFFERENTIAL DIAGNOSES AND
binge eaters meet the diagnostic criteria of COMORBIDITY
bulimia nervosa, but most of them do not.
Those who do not meet the criteria binge 6.29.6.1 Differential Diagnoses
regularly but do not engage in the characteristic
compensatory purging behaviors of bulimia Considerable weight loss can occur as a result
nervosa, that is, self-induced vomiting or use of of certain physical illnesses (e.g., cancer,
laxatives. DSM-IV considered this a possible intestinal disorders, and AIDS), depression,
eating disorder and called it the Binge Eating schizophrenia, and others. Weight loss of this
Disorder. In the diagnostic handbook, binge type must be distinguished from anorexia
eating disorder is included in an appendix listing nervosa if the patient fails to meet the other
clinical presentations which must be studied in diagnostic criteria for the eating disorder, such
detail before they can be definitely included in a as an extreme fear of being fat and the desire to
diagnostic category in the handbook. In Table 4 continue to lose weight.
the preliminary DSM-IV criteria for binge Binges can occur as a result of schizophrenia,
eating disorder are listed. depression, a borderline personality disorder,
Obese subjects who meet the criteria for the and certain neurological disorders such as the
binge eating disorder differ on several char- Kleine±Levy syndrome. If these patients do not
acteristics from obese persons who do not meet show compensation behavior and do not appear
the binge eating disorder criteria (Brody, Walsh, extremely overly concerned with their figure,
& Devlin, 1994; Castonguay, Eldredge, & Agras, they do not meet the criteria for bulimia
1995; Fichter, Quadflieg, & Brandl, 1993; Lowe nervosa.
& Caputo, 1991; Spitzer et al., 1993). Obese If patients with an eating disorder handle
binge eaters in general have a higher body mass food compulsively or are afraid of eating in
index, report more weight fluctuations, show an social situations, they do not necessarily suffer
earlier onset of obesity, spend more time dieting, from an obsessive-compulsive disorder or from
are more restrained in their eating patterns, drop social anxiety. It must first be determined
out of treatment more frequently, have poorer whether the patient also meets the other criteria
treatment outcomes, and show more psycho- for these disorders and whether, for example,
pathology than the obese nonbingers. they also suffer from obsessions, compulsions,
Observed links between obesity and psycho- or social fears that are not related to food or the
pathology (see Section 6.29.6.2) are mostly figure.
Table 4 DSM-IV research criteria for Binge Eating Disorder.
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
(1) eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely
larger than most people would eat in a similar period of time under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating)
B. The binge eating episodes are associated with three (or more) of the following:
(1) eating much more rapidly than normal
(2) eating until feeling uncomfortably full
(3) eating large amounts of food when not feeling physically hungry
(4) eating alone because of being embarrassed by how much one is eating
(5) feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least 2 days a week for 6 months
Note: The method of determining frequency differs from that used for bulimia nervosa; future research
should address whether the preferred method of setting a frequency threshold is counting the number of
days on which binges occur or counting the number of episodes of binge eating
E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g.,
purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa
or bulimia nervosa
6.29.6.2 Comorbidity impression that subjects with eating disorders

show a high incidence of psychoactive substance
Obese bingers more often than obese non- abuse, controlled epidemiological studies do not
bingers are characterized by depression, anxi- confirm this (Welch & Fairburn, 1996b; Wilson,
ety, personality disorders, low self-esteem, 1991). Also, a borderline personality disorder is
impulsivity, body perception disturbances, considered to be much more prevalent among
neuroticism, and overall distress. Obese binge subjects with eating disorders, in particular
eaters significantly more often meet criteria for bulimia nervosa, than among other psychiatric
a psychiatric disorder than obese nonbinge populations. Rates have ranged from 2% to
eaters (60% vs. 28%; Castonguay et al., 1995). 47% (Wonderlich, 1995). However, methodo-
Some authors consider depression a risk factor logically sound studies are rare; the main
for the occurrence of binges among people who problems in these studies are the absence of
are overweight (Marcus, 1995). (psychiatric) control groups and the diagnostic
Nearly half of women suffering from anor- problems related to the definition of the
exia nervosa and bulimia nervosa are depres- borderline personality disorder. There is con-
sive, whereas others show obsessions and siderable overlap between the diagnostic criteria
compulsions or other anxiety disorders. Their for eating disorders and the diagnostic criteria
first-degree relatives suffer from mood disor- for the borderline personality disorder. The
ders more often than could be expected by latter includes, for example, binge eating, mood
chance (Cooper, 1995a). In particular, patients fluctuations, unstable self-image, suicidal or
who regularly purge are clearly more depressed self-mutilating behavior, feelings of boredom
and show more anxiety than those who do not and emptiness. Because of the overlap in
regularly purge (Garner, 1993). This is why criteria, there is a risk of overdiagnosing the
from time immemorial there have been experts borderline personality disorder among (de-
who believe that eating disorders are a variation pressed) subjects with eating disorders. This
of mood and/or anxiety disorders (Garfinkel, idea is supported by data that indicate a
1995), but the symptoms of anxiety disorders decrease in the rate of borderline personality
and depression occurring during the eating disorders with short-term, symptom-focused
disorder are virtually always secondary to the interventions (Wonderlich, 1995).
eating disorder. When the eating disorder
disappears, the depressive and/or phobic char-
acteristics often disappear as well (Fairburn & 6.29.7 PREVALENCE AND PROGRESS
Cooper, 1989).
Recently, Welch and Fairburn (1996b) found Anorexia and bulimia nervosa are seen
that deliberate self-harm by repeated cutting significantly more often among women than
was much more common among a community men. About 10% of the patients are male (APA,
sample of bulimia nervosa subjects (19%) than 1994). Epidemiological research into the pre-
among a psychiatric (3%) and a normal (1%) valence of the two eating disorders suggests that
control group. Although it is a general clinical about 0.5±1% of girls and young adult women
Etiology 655
(18±30 years) suffer from anorexia nervosa, the eating disorder or people with (a predis-
while bulimia nervosa is seen in 1±3% of this position for) an eating disorder choose these
group (APA, 1994; Fairburn & Beglin, 1990). professions.
Atypical eating disorders are considered to be Anorexia and bulimia nervosa usually start
much more common (APA, 1994; Fairburn & prior to the age of 18. In 10% of the cases in
Walsh, 1995), but how common is currently which hospitalization is required, anorexia
unknown. It is difficult to collect exact data nervosa results in death (APA, 1994). The
concerning the prevalence of eating disorders. progress of the two eating disorders is highly
In addition to the fact that women with variable. Some people are cured after a short
anorexia nervosa often deny that they have episode of anorexia nervosa, while some
an eating disorder and women with bulimia regularly relapse and others suffer chronically
nervosa often keep their problem hidden from the disorder. The younger anorexia
because they are ashamed, research of this type nervosa starts and the shorter the time between
requires precise, unambiguous application of onset and presentation for treatment, the better
the diagnostic criteria. the prognosis. The progress of bulimia nervosa
Some researchers believe that the prevalence varies: 20% of the treated cases suffer chroni-
of the two eating disorders has increased in cally from the eating disorder and 30% relapse
recent decades (APA, 1994). Epidemiological now and then, in which cases periods of bulimia
studies, however, do not show an upward trend nervosa alternate with periods of normal eating
in rates (Fombonne, 1996). The alleged increase behavior (Hsu, 1995). Fifty per cent of bulimics
could be a result of the increased publicity about remain completely free of symptoms up to 10
and familiarity with eating disorders, as a result years after cognitive-behavior therapy (Hsu,
of which cases are identified more quickly. 1995). Figures for untreated cases are not
Patients or relatives turn to their family available.
physician or another expert more readily, and
the diagnostic process and the available assis-
tance have improved, so that an eating disorder 6.29.8 ETIOLOGY
is more readily recognized by all concerned.
A number of influential theories concerning
Obesity is much more common than the
the origin and maintenance of eating disorders
eating disorders anorexia and bulimia nervosa.
are discussed in this section. Their empirical
In the USA 12% of adult men and 15% of adult
validity is also examined.
women are obese, in the UK 8% and 12%,
respectively (Wardle, 1995). Binge eating dis-
order is primarily seen in overweight people and 6.29.8.1 Genetics
one and a half times more often in females than
in males (APA, 1994; Marcus, 1995). About The fact that first-degree relatives of anorexia
2±5% of overweight nonpatient community and bulimia nervosa patients suffer from an
subjects meet criteria for the binge eating eating disorder more often than could be
disorder, compared with one-third of over- expected by chance is often presented as proof
weight people who present for treatment. The that eating disorders are genetically determined.
higher the BMI, the greater the likelihood of This conclusion is not justified: a higher
binge eating. prevalence of eating disorders among relatives
Obesity is more prevalent in lower than in does not establish the genetic nature of the
higher socioeconomic groups (Foster, 1992), disorders. Such evidence can only be supplied
whereas anorexia and bulimia nervosa occur to by disentangling the influence of inherited
about the same extent in all social classes factors from environmentally transmitted fac-
(Fairburn & Beglin, 1990; Gard & Freeman, tors, for example, through studies of twins or
1996; Rogers, Resnick, Mitchell, & Blum, 1997) adopted children. By studying concordance
and appear to be more common in industri- rates of eating disorders among monozygotic
alized countries, where there is an excess of food (MZ) and dizygotic (DZ) twins, Treasure and
and the ªperfect figureº culture prevails, than in Holland (1995) found significantly more MZ
undeveloped countries. However, we do not pairs concordant for anorexia nervosa than DZ
know this for certain, because systematic studies pairs. This was not the case for bulimia nervosa,
of the prevalence in other cultures are seldom suggesting that genetic factors play a significant
made. Women in certain professions run a role in the development of anorexia nervosa,
higher risk than other women: anorexia nervosa whereas this may not be true for bulimia
is seen relatively more frequently among ballet nervosa. Thus, both eating disorders tend to
dancers, models, and athletes (professions in run in families, but, for the origin of bulimia
which a low body weight is an advantage), but it nervosa, environmental factors also appear to
is not clear whether these professions stimulate be important. Genetic influences may be more
important in the development of anorexia of subjects with bulimia nervosa. This was
nervosa. The nature of inherited factors in significantly more than the rate of sexual abuse
anorexia and bulimia nervosa needs to be in a normal control group (10%) but no
examined more closely. different from the rate of sexual abuse in
The cause of obesity is still poorly under- community controls with other psychiatric
stood. It is clear that obesity is always caused by disorders (24%), like affective disorders or
a greater energy intake over output, but the anxiety disorders. Thus, childhood sexual abuse
cause of the energy imbalance is unknown. is not directly relevant to most cases of eating
Obesity runs in families. Whether this results disorders, and the data suggest that childhood
from genetic factors or family eating patterns or sexual abuse is a nonspecific risk factor for the
maybe both is yet unknown. Adoption studies development of psychopathology in general and
point to a heredity factor for body weight: they not for the development of eating disorders in
show that adopted children have weights more particular. However, self-report data have
closely related to their biological than to their serious limitations: over-reporting, under-re-
adoptive parents, and monozygotic twins porting, and retrospective distortion may play
resemble each other more than dizygotic twins, parts in skewing the data, suggesting that care is
whether they have grown with each other or not needed in their interpretation (Esman, 1994),
(Foster, 1992). According to some experts, the especially when the influence of neuroticism and
heritability factor is not a gene for excess body depression is not controlled for.
weight, but a vulnerability to obesity that is
expressed under suitable environmental circum- 6.29.8.3 Dieting for the Perfect Figure
stances (Drewnowski, 1996; Wilson, 1994).
There are also some indications that the obese It has been found in many studies that
are characterized by inherited metabolic effi- physically attractive people are considered to be
ciency which enables them to gain or maintain overendowed with favorable qualities. Beautiful
weight easily. For example, obese children tend people are considered more interesting, stron-
to have obese parents, and research has shown ger, friendlier, more intelligent, and more
that the energy expenditure of normal weight sexually exciting than less beautiful people;
offspring of obese parents was only about 80% appearance is unrelated to these qualities. As a
of that found in normal-weight children of result of the wonderful qualities attributed to
nonobese parents (Foster, 1992). However, attractive people, their lives become even better
there is also evidence for distorted eating than they would otherwise be: they are more
patterns in the obese. In general, obese persons likely to receive assistance during conflicts, are
are found to eat more than their lean counter- more likely to get the job they apply for, and are
parts, and there are indications that childhood less likely to be found guilty in a court of law
obesity is triggered by overeating (Foster, 1992). (Feingold, 1992).
Moreover, the obese show a preference for fat, It has therefore been suggested that the media
and their diet indeed is richer in fat than diets of systematically present distorted information
lean persons. Children's preferences for fat food about the ideal figure and the perfect body,
were not only influenced by their own body dictating weight standards that are unobtain-
fatness, but also by the fatness of their mother, able for women or only obtainable by consider-
which led Drewnowski (1996) to hypothesize able effort; being beautiful makes life much
that the genetic vulnerability is an increased more pleasant while being fat is generally not
appetite for energy-dense fat-containing foods. considered attractive; therefore many women
use extreme measures to lose weight and
6.29.8.2 Childhood Sexual Abuse consequently develop an eating disorder.
A number of facts appear to support this train
The fact that a large proportion of patients of thought. Eating disorders are seen much more
with eating disorders and people who have often among women and girls than among men
suffered from sexual abuse have low self-esteem and boys. Eating disorders are also reported to
and tend to feel shame about their body led be more common in the Western, industrialized
some authors to relate childhood sexual abuse countries where women compare themselves to
to the development of eating disorders (e.g., extremely skinny models than in non-Western
Andrews, 1997). Some recent large-scale and cultures where this type of figure is not
well-controlled studies show that self-reported considered to be as ideal. Women with a typically
childhood sexual abuse is present in about female distribution of fat (broad hips, buttocks,
25±35% of the eating-disordered subjects (Vize and upper legs) suffer more often from eating
& Cooper, 1995; Welch & Fairburn, 1994; disorders than women with a figure that is more
1996a). Welch and Fairburn (1994) found a rate male (narrow hips, buttocks, and legs). Lesbians
of 26% for sexual abuse in a community sample suffer less often from eating disorders than
Etiology 657
heterosexual women, while homosexual men are be triggered. According to the set-point theory,
more likely to develop eating disorders than patients with bingeing urges have dropped
heterosexual men (it is assumed that homosexual below their set-point weight.
women are less influenced by the ideal female The theory is elegant, but there are a few
figure, while outward appearance is more anomalies. In the first place, patients with
important to homosexual men than to hetero- anorexia nervosa are the perfect example of
sexual men) (Brand, Rothblum, & Solomon, malnourished dieters. Nevertheless, only half of
1992). In our culture, a slim figure is appreciated these patients report suffering from bingeing
and striving to lose weight causes a lot of women urges. Second, there are dieters who never
eating problems, simply because they inherited a overeat; they are called ªsuccessfulº dieters. A
figure whichÐaccording to our cultural German study indicated that about one-half of
standardsÐis not ideal. every one thousand women diet without any
The idea that our culture overvalues the problems (Westenhoefer, Pudel & Maus, 1990);
ªperfect figureº and therefore causes eating in England and the USA, documented studies
disorders is, nevertheless, an oversimplification indicate that ªonlyº 8±9% of dieting women and
of the facts. The perfect-figure culture is girls suffer from bingeing urges or develop an
something that is applicable to all women in eating disorder (Agras, 1990; Patton, Johnson-
Western society. If the perfect-figure culture did Sabine, Wood, Mahn, & Wakeling, 1990). The
in fact cause eating disorders, there would be set-point mechanism is therefore not nearly as
epidemics of these disorders. This is not the case. dominant as suggested. Apparently, many
It would appear more likely that the ªperfect- people can diet and lose weight to below the
figure cultureº stimulates women to diet to lose set-point level without any problems. Further-
weight, thereby increasing the risk of an eating more, it does not appear likely that dieters with
disorder. Why? bingeing urges are below their set-point weight: a
Binges go hand in hand with the intention to number of studies have indicated that dieters
limit the intake of food (Polivy & Herman, 1985); have a higher BMI and eat the same amount or
retrospectively, it was found that about 80% of even more kilocalories (and retain that energy)
patients with bulimia nervosa tried to lose weight than nondieters (see, e.g., Jansen, 1996). Of
by strict dieting prior to the onset of binge eating course, one might put forward the untestable
(Rossiter, Wilson, & Goldstein, 1989); about and circular argument that the bingeing dieters
50% of anorexia nervosa patients develop binge have a higher set-point than the normal eaters;
eating episodes about 9±18 months after the advocates of the set-point theory still have the
onset of strict dieting (Polivy & Herman, 1985); formidable task of discovering how a person's
and nonclinical dieters report significantly more set-point weight can be determined.
binge eating than nondieters (Wardle, 1980). Studies of the relationship between dieting
The set-point theory explains the relationship and bingeing are usually retrospective or
between dieting and binge eating. According to correlative and they thus do not render any
that theory, every organism has a certain certainties with reference to causality. It there-
amount of fat that has been predetermined fore cannot be proven that dieting is not a
for life. The idea is that the amount of fat consequence of a tendency to regularly overeat
present in an organism is continuously regis- or that there is not a third factor involved; an
tered. A homeostatic mechanism is responsible underlying mechanism that explains both the
for keeping the amount of fat balanced. If, in dieting and the bingeing.
comparison with the predetermined amount of Briefly summarized: the ªperfect-figureº
fat, a shortage of fat is identified, processes are culture prescribes a female figure that most
activated that bring the quantity of fat up to the women will never be able to achieve. This is why
set-point level. If too much fat is identified, many women diet. In about 9% of the cases,
processes are activated that bring the quantity dieting results in an eating disorder. This makes
of fat back down to the set-point level (Keesey, it improbable that the ªperfect-figureº culture
1995). According to this theory, people with a and dieting are the key determinants of eating
low set-point weight in our ªperfect-figureº disorders; if this were the case, a considerably
culture are just plain lucky. The people with bad larger number of women would suffer from
luckÐa high set-point weightÐare condemned eating disorders.
to being ªoverweightº for their entire lives.
When these peopleÐfor instance, when influ- 6.29.8.4 Serotonin Depletion
enced by the concept of a ªperfect-figure'Ðstart
to diet and lose weight, their weight drops below First-degree relatives of patients with an
their own set-point weight. Then the body eating disorder not only have eating disorders
responds with mechanisms designed to regain more often, but mood disorders are also more
weight: bingeing and a slower metabolism can common than would be expected. Nearly half of
patients with eating disorders are also diag- in serotonin. This increase will not be achieved
nosed as suffering from depression (Laessle, unless excessive amounts of carbohydrates are
1990). The association of the two disorders consumed during a binge. A binge could,
within families and individuals led to the therefore, be considered a type of ªself-
hypothesis that eating disorders are in fact a medication.º
type of biological mood disorder. This will be Indeed it was found, analogous to the finding
discussed further below. from the animal experiment of the Wurtmans
Various studies identified a relationship (Wurtman & Wurtman, 1984), that the con-
between eating carbohydrates and mood. Eat- sumption of a standard quantity of carbohy-
ing a proportionately large amount of carbohydrates by patients with bulimia nervosa did not
drates results in a better mood (Fichter & Pirke, result in the expected increase in the tryptophan
1995; Jansen, van den Hout, & Griez, 1989; ratio. Tryptophan is a large neutral amino acid,
Wurtman & Wurtman, 1984). This mood and its ratio to other large amino acids
improvement is assumed to be mediated by determines the amount of tryptophan entering
the neurotransmitter serotonin: by eating the brain. A larger ratio means more tryptophan
relatively large amounts of carbohydrates and entering the brain, resulting in increased
little protein, serotonin production in the brain serotonin levels in the brain. What's more,
increases. The increased serotonergic activity eating carbohydrates did not stop until the
results in mood improvement. A shortage of tryptophan ratio in the blood plasma reached a
carbohydrates, by contrast, results in a decrease normal level (see Pirke, 1995). Others found a
in the amount of serotonin in the brain. In turn, lower concentration of the serotonin metabolite
this results in a lowering of mood. 5-hydroxyindoleacetic acid (5-HIAA) in the
The amount of serotonin in the brain cerebrospinal fluid (CSF) of severe bulimic
determines not only mood state but also the patients (Jimerson, Lesem, Kaye, & Brewerton,
craving for carbohydrates. As the amount of 1992). The quantity of 5-HIAA in the CSF
active serotonin decreases, an increased craving reflects the amount of serotonin active in the
for carbohydrates is observed. It can therefore brain; the data thus point to a low turnover of 5-
be hypothesized that the production of seroto- hydroxytryptophan (5-HT) in subjects with
nin in the brain is in part dependent on the severe bulimic symptoms. However, a study
amount of carbohydrates consumed. Eating a with weight-restored anorexics indicates that
larger amount of carbohydrates results in more abnormalities in central serotonin function
serotonin being produced in the brain. As a follow from weight loss and malnutrition and
result, mood improves and the craving for are not related primarily to the disorder itself
carbohydrates diminishes. If, however, too few (Odwyer, Lucey, & Russell, 1996).
carbohydrates are consumed, less serotonin is Caution is also advised when the findings are
produced, mood declines, and the craving for presented as evidence supporting the theory that
carbohydrates increases. binges serve to increase the quantity of
Animal experiments have shown that depri- serotonin in the brain. In the above-mentioned
vation of carbohydrates seriously disrupts the studies, it is assumed that the food patients
carbohydrate regulation as described above. consume during binges is rich in carbohydrates,
After rats were deprived of carbohydrates for a whereas this is not the case. It has repeatedly
short period, cerebral sertonin level decreased as been found that patients with bulimia nervosa
predicted. It was striking that serotonin did not eat as much carbohydrates during the binges as
reach the normal level again until after an they do in between binges (Jansen, van den
excessive amount of carbohydrates was con- Hout, & Griez, 1989; Walsh, 1993). Moreover,
sumed (Wurtman & Wurtman, 1984). in both periods they consume the same amount
These and other findings resulted in the of carbohydrates as a normal control group.
following hypothesis concerning the origin of However, it should also be noted that a recent
binges among patients with bulimia nervosa (see study among healthy female subjects shows that
also Figure 1): for a variety of reasons, for even moderate dieting on a diet with a normal
example the desire to fulfill the cultural ideal of macronutrient composition (1000 kcal, 31%
the female figure, some women subject them- protein, 44% carbohydrate, 25% fat) causes
selves to a rigid eating regime. If this eating increased sensitivity of 5-HT receptors in the
regime results in too few carbohydrates being brain (Cowen, Clifford, Walsh, Williams, &
consumed, successfully following the strict Fairburn, 1996), suggesting that the overall
regime will result in disruption of the seroto- decrease in the neurotransmission of serotonin
nergic system on the cerebral level. By depriving during dieting does not require a relative
themselves of carbohydrates for longer periods carbohydrate depletion.
of time, consumption of carbohydrates later will The serotonin hypothesis concerning the
not immediately result in the required increase origin of bingeing is important, but it must as
Etiology 659
5 HT (serotonin)
mood binge
5 HT (serotonin)
Figure 1 The serotonin model of binge eating.
yet be proven that the bingeing truly serves to analogy between bulimia nervosa and addiction
increase the serotonin level in the brain. may teach us something about the origin of
Findings suggesting that other psychiatric binges. Excessive consumption of food during a
disorders may be characterized by low serotonin binge is often related to a configuration of
levels in the brain also generate the question of specific stimuli. Think in this respect of seeing,
why these patients do not suffer from bingeing smelling, and tasting rich food, emotional
as a type of self-medication. confusion (a somber mood, fear, boredom, or
loneliness), certain disinhibiting thoughts, and
the time of the day. When repeatedly and
6.29.8.5 The Learned Nature of Binge Eating exclusively combined with the bingeing, these
Recent studies in the area of addiction suggest stimuli become excellent predictors for a binge.
that the urge to consume a substance is a Impressive data from experiments with animals
classically conditioned response (Drummond, indicate that eating behavior can be induced by
Tiffany, Glautier, & Remington, 1995; Siegel, stimuli that are repeatedly associated with the
1983). Addicts normally use a substance in the intake of food (Wardle, 1990; Woods, 1991).
presence of certain stimuli, for example, their According to this theory, the stimuli that
favorite pub, drinking or shooting buddies, the predict the binge continually induce prepara-
bottle, the syringe, the spoon and the silver foil. tory physiological responses in the eater (see
In a long series of experiments, it was shown Jansen, 1994, in press). The model predicts that
that stimuli the nature of their exclusive the physiological responses are experienced as a
presence eventually predict the use of a virtually irresistible urge to consume food and
substance resulting in the addict having pre- therefore increase the chance of a binge. It
paratory physiological reactions. Even before remains, however, to be seen whether this model
any substance is swallowed, injected, or inhaled, for the origin of binges will be confirmed by
changes occur in the body. These anticipative empirical studies.
physical changes are said to be experienced as a
virtually uncontrollable urge to consume the 6.29.8.6 Dysfunctional Cognitions
substance, and striking is the fact that the
occurrence of physical reactions after successful Excessive worry about the figure, appear-
withdrawal accurately predicts a relapse ance, and weight, as already indicated, is
(Drummond et al., 1995). characteristic for patients with an eating
Patients with bulimia nervosa show some disorder. The extreme worries about appear-
striking similarities with addicts. Both are ance and weight probably represent the core of
preoccupied with the substance that they use the eating disorders. Thinness is idealized, and
excessively, both experience an urge to consume the feeling of being fat fuels the drive to lose
the substance, and both are characterized by weight. Eating-disordered subjects continually
loss of control during consumption. The evaluate themselves in terms of outward
appearance and weight. They tend to judge self- other things, the model predicts that (i) subjects
worth almost exclusively in terms of body shape with eating disorders are characterized by
and weight and, therefore, often show long- negative self-evaluation or low levels of self-
standing negative self-evaluation (Fairburn, esteem, (ii) low self-esteem is closely related to
1997a). Being fat is associated with being the extreme concerns about body shape and
worthless, unlikable, disgusting, and so on; weight, and (iii) long-term treatment success is
being skinny means being attractive, successful, related to a reduction of the overconcern about
intelligent, happy, and so on (Vitousek & body shape and weight. Furthermore, it is
Hollon, 1990). This method of self-evaluation predicted that (iv) a binge is caused by
is remarkable because in all cases of anorexia disinhibitive thoughts such as ªmy day is ruined
nervosa and in most cases of bulimia nervosa, now, I might as well continue to eat.º Let us
patients are not objectively overweight at all. Of review the evidence.
course, the evaluation of a person is dependent The first hypothesis (subjects with eating
on much more than his outward appearance disorders are characterized by low levels of self-
alone. It is more usual to judge self-worth on the esteem) has indeed been supported in diverse
basis of performance in a variety of domains, questionnaire and interview studies (see, e.g.,
like work, sports, friendships, relationships, and Mizes & Christiano, 1995). Also a prospective
so on (Fairburn, 1997a). According to the study on the development of eating disorders
cognitive view on the maintenance of anorexia showed that 11- and 12-year-old dieting girls
nervosa and bulimia nervosa (Fairburn, 1997a), with low self-esteem were at significantly greater
the overvalued ideas about the significance of risk of developing eating disorders at the age of
body shape and weight are at the heart of the 15±16 than dieting girls with normal and high
eating disorders. Self-evaluation is unduly self-esteem (Button, Sonagu-Barke, Davies, &
influenced by how the subject perceives her Thompson, 1996). Considering hypothesis (ii)
body shape and weight. The preoccupation with (the low self-esteem is closely related to the
food, eating, dieting, and weight control overconcern about body shape and weight),
methods are supposed to be secondary to this questionnaire studies indicate that subjects with
overconcern. eating disorders perceive weight and eating as
The model states that binge eating follows the basis of approval from others, whereas
from a particular type of dieting: intense and control subjects do not (Mizes & Christiano,
rigid dieting. It is postulated that eating- 1995). However, self-report data on the
disordered subjects are characterized by per- assumed link between mental concepts have
fectionism and black-and-white (all-or-nothing) serious limitations. There is little experimental
thinking, which also becomes manifest in their research investigating the direct link between
way of dieting. The idea is that breaking one of low self-esteem and overconcern with body
their diet rules, even after a minor dietary shape and weight. In an analog study with
transgression, results in the view that their diet is restrained eaters, Eldredge, Wilson, and Whaley
ªtotally broken,º which ends up in a total loss of (1990) hypothesized that highly restrained
control and thus a binge (Fairburn, 1997a; eaters experiencing failure in an achievement
Herman & Polivy, 1984). This is said to be task would react more negatively towards their
accompanied by typical, disinhibiting auto- own bodies than restrained eaters who experi-
matic thoughts along the lines of ªmy day is enced success. They found that the highly
already ruined, I might as well continue to eatº restrained eaters experiencing failure did not
and ªI'm trying not to eat. If I eat anyway, I feel worse about their bodies than the highly
might just as well continue to eat,º reflecting restrained eaters experiencing success. Others,
their perfectionism (Garner, 1986). Thus, if however, did find evidence for the link between
eating-disordered subjects feel as if they have self-evaluation and body concern. It was found
eaten too much, they consider their diet a failure that activation of thoughts about eating,
for that day and eat too much the rest of the day. weight, and shape led to an increase in negative
Disinhibiting, all-or-nothing thoughts are self-statements (Cooper, Clark, & Fairburn,
therefore supposed to be responsible for the 1993) and, the other way around, presentation
onset of the binge. of negative events involving the self led to
The cognitive view on the maintenance of weight and shape explanations in eating-
anorexia nervosa and bulimia nervosa is at the disordered subjects (Cooper, 1997). Further-
moment the most widely accepted model of more, a recent study from our lab (Meijboom,
eating disorders. Strikingly, considering the Jansen, Kampman, & Schouten, in press)
popularity and plausibility of the cognitive view showed that priming low self-esteem in highly
on the maintenance of eating disorders, there is restrained subjects facilitated the accessibility of
little direct empirical evidence for most of the subliminally presented body shape and weight
hypotheses flowing from the model. Among words. The latter three findings support the idea
Treatment 661
that concern with body shape and weight is broken), it was assumed that the manipulation
linked to self-esteem in eating-disordered sub- prevented the occurrence of disinhibitive
jects. However, much more experimental re- thoughts. Contrary to what the cognitive model
search is needed before any definite conclusions predicts, it was found that dieters who were
about the link, and its causal relationship, merely exposed to, and intensively smelled the
between self-esteem and overconcern with body food, but whose diets were not actually broken
shape and weight can be drawn. It might, for or threatened, overate (Jansen & van den Hout,
example, be an interesting enterprise to test 1991). Contrary to hypothesis (iv), the absence
whether priming body shape and weight words of disinhibiting thoughts did not prevent dieters
will lead to higher accessibility of (low) self- overeating.
esteem stimuli. Furthermore, it is necessary to All in all, there is evidence that subjects with
test experimentally whether reducing the overeating disorders are characterized by low self-
concern about body shape and weight will esteem, and there is some support for the
increase self-esteem, whereas an activation of hypothesis that low self-esteem is linked to
the overconcern about body shape and weight in extreme concerns about body shape and weight.
normal dieters will decrease their self-esteem. However, much more experimental research on
There is some evidence for hypothesis (iii) the precise link between self-esteem and body
(long-term treatment success is related to a shape evaluation is needed before firm conclu-
reduction of the overconcern about body shape sions can be drawn. Furthermore, there is
and weight). Fairburn, Peveler, Jones, Hope, hardly any empirical evidence for the idea that
and Doll (1993) showed that the severity of disinhibiting thoughts cause binge eating.
concerns about shape and weight at the end of There have been more studies on the cogni-
treatment were directly related to the likelihood tions of subjects with eating disorders than the
of relapse: 9% of the subjects with the least studies cited above (for an overview see Vitousek
concerns relapsed vs. 19% of those with a & Hollon, 1990). Remarkably, however, the goal
moderate level of concern and 75% of those of most of those studies was to verify that eating-
with the greatest level of concern. disordered subjects show cognitive distortions
Considering hypothesis (iv), clinical notes concerning food, eating behavior, body shape,
indeed indicate that a binge is caused by and weight. For example, in the modified Stroop
disinhibiting thoughts such as ªmy day is ruined test, it has repeatedly been found that subjects
now, I might as well continue to eat.º However, with eating disorders selectively process stimuli
such clinical impressions have received little related to food, eating, body shape, and weight.
empirical support. In our laboratory, the It has also been found that they show a memory
prediction was studied in bogus taste experi- bias for fatness words (Sebastian, Williamson, &
ments, but it could not be demonstrated that Blouin, 1996). This kind of research may be
disinhibiting thoughts play a significant role in based on circular reasoning; subjects are selected
the onset of overeating (Jansen, Merckelbach, for their abnormal cognitive processes concern-
Oosterlaan, Tuiten, & van den Hout, 1988; ing body shape, weight, food, and eating, and it is
Jansen & van den Hout, 1991). There is, concluded that they are characterized by an
however, some circumstantial evidence consis- abnormal processing of body shape, weight,
tent with the idea that the activation of food, and eating information.
disinhibiting thoughts in normal dieters can
elicit bingeing. In a laboratory study with high
and low restrained eaters, Spencer and Fre- 6.29.9 TREATMENT
mouw (1979) manipulated their subjects' beliefs 6.29.9.1 Anorexia Nervosa
concerning the caloric content of a preload and
demonstrated that the restrained eaters overate Traditionally, anorexia nervosa is treated on
after the preload when they only thought they an inpatient basis with a program to increase
had overeaten during the preload. It was not weight, loosely based on operant conditioning.
clear, however, whether the overeaters were The patients are admitted to the clinic and it is
characterized by more disinhibitive thoughts. agreed that they will gain a predetermined
Whether a straightforward activation of disin- amount of weight each week. They are
hibitive thoughts elicits a binge has never been prescribed lots of bed rest (so that they will
tested. A final prediction following from the burn less energy), and a number of pleasant
hypothesis is that a reduction of disinhibitive pastimes (receiving visitors and watching tele-
thoughts prevents a binge. There is an experi- vision, for example) are forbidden. They can
mental finding which counters this prediction. gradually earn back these pleasant pastimes by
Dieters were led into temptation to eat by gaining the desired amount of weight. The
smelling very palatable food. Because they effectiveness of treatments of this type has never
merely smelled the food (their diet was not been established; the clinical impression is that
patients gain weight during the treatment but After the therapy, a reduction in binge and
quickly relapse after leaving the clinic. Perhaps purge frequency of about 80% has been
this is caused by the overemphasis on the sole observed and about 55% of the patients stopped
goal of gaining weight. Anorexia nervosa bingeing altogether (Fairburn, 1995; Wilson,
consists of more than simply being considerably 1996a). The patients also show more normal
underweight. Its core psychopathology consists attitudes towards their body shape and weight.
of cognitive distortions concerning body shape In one study, patients were followed for a period
and weight, which probably do not change of six years. The long-term results are also
during a treatment that is solely oriented favorable: after six years there is virtually no
towards gaining weight. relapse (Fairburn et al., 1995).
For this reason, today many (but not all) Cognitive-behavior therapy for eating dis-
inpatient treatment programs are much more orders in fact is a multicomponent treatment
versatile. In addition to focusing on gaining package including, among others, self-control
weight, the patients learn to accept their body, techniques, self-monitoring, education, diet
for example, by video confrontation, and talk management, cognitive restructuring, problem-
about emotions. They are often given nutri- solving training, interpersonal training, and
tional counseling and family therapy. Focus is relapse prevention. A relevant question of
also placed on increasing self-esteem and course is: which of these treatment components
improving social skills (Fichter, 1995). The are necessary to effect positive response? For
effectiveness of treatments of this type, how- researchers on eating disorders, the time is here,
ever, has not been empirically confirmed. now to identify the effective parts of cognitive-
As long as the patient's physical condition behavior therapy as well as to identify the
makes it possible, outpatient treatment is mechanisms of action, that is, the mechanisms
preferred above intramural treatment. Re- by which the effective treatment parts achieve
cently, it has been argued that patients with changes.
anorexia nervosa would, like subjects with There has been one treatment that may be as
bulimia nervosa, benefit from outpatient cog- effective as cognitive-behavior therapy: inter-
nitive behavior therapy, a treatment which is personal psychotherapy (Fairburn, 1997b).
focused on changing maladaptive thoughts, During this short-term focal psychotherapy,
feelings, and behavior (Fairburn, Marcus & little attention is paid to the eating disorder
Wilson, 1993; Vitousek, 1995). Again, however, symptoms, instead the treatment focuses on the
the effectiveness of cognitive-behavior therapy identification and modification of current
in the treatment of anorexia nervosa also interpersonal problems. In the long run, inter-
remains to be established. personal therapy proved to be as effective as
Antidepressants are the most commonly cognitive-behavior therapy. The idea is that the
prescribed medications for anorexia nervosa; treatment is successful because it improves
however, in the long run they do not appear to interpersonal functioning and thereby self-
be effective. The reason for this ineffectiveness worth, meaning that self-evaluation is less
may be that antidepressants do not affect the dependent on body shape and weight, which
morbid attitudes, beliefs, and associated beha- makes dieting less necessary and so the eating
viors which constitute the central features of the disorder gradually erodes (Fairburn, 1997b).
illness (Wakeling, 1995). However, the assumed mechanism by which the
treatment brings about change still has to be
6.29.9.2 Bulimia Nervosa studied, and more controlled trials are needed
before any firm conclusions about the robust-
The effectiveness of treatments for bulimia ness of the effects can be drawn.
nervosa have been studied in numerous con- A rather new and promising approach is the
trolled studies. Cognitive-behavior therapy, cognitive-behavioral body image therapy
based on the cognitive model of eating disorders (Rosen, Reiter, & Orosan, 1995). Considering
(see Section 6.29.8.6), has been shown to be the the fact that the severity of concerns about shape
most effective therapy. For the present, it must and weight at the end of treatment are related to
be the treatment of choice for bulimia nervosa. the likelihood of relapse (Fairburn et al., 1993), it
A detailed manual was developed by Chris is argued that maintenance of recovery without
Fairburn (see, e.g., Fairburn, 1997a) focusing significant body image changes will be a
on disrupted eating behavior, the cognitive continuous struggle (Rosen, 1995). The body
distortions concerning body shape and weight, image therapy is divided into two parts: (i)
and the long-standing negative self-evaluations cognitive restructuring, and (ii) exposure. Dur-
of subjects with eating disorders. In about ing the cognitive part, subjects keep a body
twenty 50-minute sessions over 20 weeks, the image diary in which they record situations that
patient learns to eat and think more normally. provoke concerns about appearance, body
In Conclusion 663
image beliefs, and the effect of both on mood and fulfilling (Smith, Marcus, & Kaye, 1992;
behavior. Irrational, dysfunctional thoughts Wilson, 1994). Binge eaters may also benefit
about the body and damaging beliefs concerning from cognitive-behavioral self-help treatment
self-worth are challenged and restructured. manuals (Cooper, 1995b; Fairburn, 1995a). In a
Furthermore, the patient gradually exposes couple of studies they have proved to be an
herself to a hierarchy of distressing aspects of effective treatment method to combat binge
appearance, and during the exposure the goal is eating. They can be used independently by
to change negative self-talk in nonjudgmental sufferers on their own, or with guidance from a
self-descriptions (Rosen, 1995). A further goal is nonspecialist therapist (Fairburn, 1997a; Fair-
to reduce or prevent body-checking behavior. burn & Carter, 1997).
Body image therapy has been shown to be Finally, there are preliminary data pointing to
effective (Rosen, 1995), but it is surprisingly cue exposure as a successful method for the
infrequently applied. treatment of binge eating (Jansen, in press;
Medication for bulimia nervosa has mainly Jansen, Broekmate, & Heymans, 1992). In vivo
focused on the use of antidepressant drugs. exposure with response prevention is a therapy
Considering binge frequency, the drugs establish which has been successfully applied for many
a reduction in binge frequency of about 60% years in the treatment of anxiety disorders.
with an abstinence rate of 22% (percentage of Subjects are repeatedly exposed to the stimuli
subjects that stopped binge eating completely). they are afraid of, and during the exposure their
However, the effects are only maintained when anxiety gradually extinguishes. From the learn-
subjects remain on the drugs. When medication ing model on binge eating (see Section 6.29.8.5),
is stopped, recurrence of binge eating is it follows that the urge to binge will also be
frequently seen, so the maintenance of change extinguished during exposure to the cues which
is poor (Fairburn, Agras, & Wilson, 1992). predict a binge. By repeatedly exposing patients
Furthermore, it seems that the drugs do not for long periods to the stimuli that predict a
influence attempts to diet, cognitive distortions binge with response prevention (eating is not
concerning body shape and weight, nor the allowed), the stimuli eventually lose their pre-
longstanding negative self-evaluations of sub- dictiveness. Once the stimuli are no longer pre-
jects with bulimia nervosa. Moreover, compara- dictors for a binge, there is no point in preparing
tive trials show that cognitive-behavior therapy the body for consumption. The preparatory
is superior to medication, and a combination of physical reactions no longer occur and the urge
medication and cognitive-behavior therapy is to binge has disappeared. The data from five,
not convincingly more effective than cognitive- largely uncontrolled and small-scale studies are
behavior therapy alone (Wilson, 1996a). promising (see Jansen, 1998).
6.29.9.3 Obesity and Binge Eating Disorder 6.29.9.4 Predictors of Treatment Outcome
Obesity has, so far, proved to be refractory to An important clinical issue is whether it can
most treatment methods (Wilson, 1994). The be predicted who will respond to treatment.
behavioral weight loss programs, which are However, reliable predictors of treatment out-
focused on dieting and self-control strategies, come have not yet been identified. In some but
produce short-term weight loss but are ineffec- not all studies, weight, premorbid and paternal
tive in the long run. Recently, Wilson (1996b) obesity, self-esteem, personality disorders, and
has argued that the narrow focus on weight loss binge eating have been identified as predictor
only may no longer prove acceptable, and he variables (Wilson, 1996a). These studies show
proposes a change of treatment goals. He argues that the worst outcome is found in subjects with
that treatment of the obese should focus on the lower weight, higher premorbid and paternal
enhancement of self-acceptance, predicting that weight, lower self-esteem at the start of the
increased self-acceptance of the obese might treatment, comorbid borderline personality
lead to more lasting changes in eating and disorders, an early onset of binge eating, and
exercise behavior. more severe binge eating. However, the data on
Treatment of the binge eating disorder has these negative prognostic factors are not
been studied only minimally. Cognitive-beha- conclusive; more and better research is needed.
vior therapy appears to be partly effective for
patients suffering from a binge eating disorder. 6.29.10 IN CONCLUSION
Loss of weight is not achieved, but no more
weight is gained, binge frequency decreases, The eating disorders anorexia nervosa and
mood improves, dissatisfaction with the body bulimia nervosa are characterized by: (i)
decreases, self-esteem increases, interpersonal abnormal eating behavior, (ii) the use of
skills improve, and marriages become more unusual methods to control weight, and (iii)
irrational and dysfunctional ideas about the disorders may also be accompanied by a lack of
patient's own body and weight, leading to serotonin. Moreover, it has been repeatedly
negative self-evaluation. Because the patients shown that the food patients with bulimia
feel fat and are afraid to gain weight, they nervosa consume during a binge does not
continually strive to lose weight. In the case of contain more carbohydrates than either the
anorexia nervosa, this results in a decrease in food they consume between binges or the food
weight of at least 15% compared with the consumed by a normal control group, findings
person's normal weight. People with bulimia which do not support the self-medication
nervosa usually have a normal weight, often hypothesis.
because of binges that regularly disrupt Various experimental findings suggest that
attempts to lose weight. During binges, con- overeating is a learned behavior. Predictors or
siderable quantities of food are consumed, and cues of excessive eating trigger a craving for
after the binge the patient vomits, uses laxatives, food for as long as they continue to predict a
or starts extreme dieting. Weight control binge, meaning as long as they are system-
measures of this type are partly effective: the atically followed by excessive food consump-
patient gains virtually no weight. However, they tion. They will always trigger a physical
do not prevent some of the food from being preparatory response which is experienced as
absorbed by the body, as a result of which the craving or an urge to eat. The model is
patient does not lose an extreme amount of confirmed post hoc by a variety of findings,
weight. but there is no direct empirical evidence that
Obesity is not an eating disorder as presently supports this theory on the origin of binges.
defined, but a subgroup of the obese is found to Irrational cognitions concerning one's body
fulfill the criteria of the binge eating disorder. shape, weight, eating, and food are character-
Like subjects with bulimia nervosa, they are istic for patients with anorexia and bulimia
characterized by objective binges during which nervosa. The precise role they play in the
they eat a large amount of food and lose control etiology and maintenance of the eating dis-
over intake. However, contrary to subjects with orders is, however, as yet unknown. In terms of
bulimia nervosa, they do not engage in the the proposed cognitive origin of binge eating, it
characteristic compensatory purging behaviors appears at this time that binges do not
of bulima nervosa. automatically follow irrational disinhibiting
It is (as yet) unknown how the eating thoughts, for example, ªmy day is ruined
disorders originate. A number of influential anyway, I may as well continue to eat.º
theories have been discussed here. There is Despite the fact that little is known about the
evidence for a genetic component in anorexia exact causes of eating disorders, bulimia
nervosa and obesity, but not in bulimia nervosa. nervosa can be effectively treated. Cognitive
However, what exactly is inherited is still behavioral therapies are the most successful
unknown. methods. They have a behavioral and a
The ªperfect-figureº culture appears to be cognitive component; the focus is on both
more of an explanation for the common dieting learning to eat normally and changing irrational
among women. This does not explain the origin thinking (about body shape and weight as well
of eating disorders because ªonlyº a fraction of as food intake). New cognitive-behavioral
the dieters (9%) develop an eating disorder. approaches such as the exposure to binge
Dieting is related to binge eating; however, their provoking cues as well as the exposure to
cause and effect relationship is unclear. Em- appearance, are promising and need to be
pirical data show that dieting is not necessarily studied further. The treatment of obesity is
required for binge eating to occur, and it is also disappointing; most treatment methods are
clear that dieting is not sufficient for eating ineffective in the long run. Obese binge eaters
disorders, including binge eating, to occur. may benefit from cognitive-behavior therapy;
The serotonin hypothesis offers an explana- although weight loss is not achieved, weight
tion for the isolated act of bingeing and for the gain is prevented, binge frequency decreases,
coherence between eating disorders and depres- and well-being improves. Finally, less is known
sion. Too little serotonin in the brain is said to about the effectiveness of treatments for
result in a virtually uncontrollable craving for anorexia nervosa: unfortunately, to date, vir-
carbohydrates and low mood. Eating an tually no properly controlled studies have been
excessive amount of carbohydrate is said to performed.
restore the serotonin level in the brain and, as a
type of ªself-medication,º to improve mood.
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Comprehensive Clinical Psychology Volume 6

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Comprehensive Clinical Psychology

Comprehensive Clinical Psychology. Volume 6

Copyright © 2000 Elsevier Science Ltd. All rights reserved.

6.02 Behavioral Approaches, Pages 25-49, J&#xfc;rgen Margraf

6.03 Cognitive Therapy, Pages 51-84, Ivy-Marie Blackburn

6.05 Psychodynamic Approaches, Pages 107-134, Peter Fonagy

6.06 Psychopharmacology, Pages 135-161, Philip J. Cowen

6.07 Experiential Treatments: Humanistic, Client-centered, and Gestalt Approaches,

6.09 Arousal Reduction Methods: Relaxation, Biofeedback, Meditation, and Hypnosis,

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6.13 Preventive Goals and Indirect/Consultation Strategies: Meeting Current Needs

6.15 Group Therapy: A Cognitive-behavioral Interactive Approach, Pages 319-337,

6.17 Obsessive-compulsive Disorder, Pages 367-398, Gail S. Steketee Randy O. Frost

6.18 Panic Disorder and Agoraphobia, Pages 399-437, Paul M. Salkovskis

6.21 Social Phobia, Pages 475-498, Harlan R. Juster Richard G. Heimberg

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6.26 Cognitive Approach to Understanding and Treating Pathological Gambling, Pages

6.27 Sexual Problems: Dysfunction, Pages 603-621, W. P. De Silva

6.29 Eating Disorders, Pages 649-667, Anita Jansen

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The Development of Psychological Treatments

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In parallel with the development of psychological treatments for psychological problems,

Specific Psychological Problems and General Topics

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BLUE, J. (Philadelphia College of Osteopathic Medicine, PA, USA)

BOOKER, K. (University of California, Santa Barbara, CA, USA)

BORKOVEC, T. D. (Pennsylvania State University, University Park, PA, USA)

BOUMAN, T. K. (University of Groningen, The Netherlands)

BUTLER, G. (University of Oxford, Warneford Hospital, UK)

COWEN, P. J. (University of Oxford, Warneford Hospital, UK)

DAHLSGAARD, K. K. (University of Pennsylvania, Philadelphia, PA, USA)

DATTILIO, F. M. (University of Pennsylvania School of Medicine, Philadelphia, PA, USA)

DAVIDSON, R. J. (Belvoir Park Hospital, Belfast, UK)

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DE SILVA, W. P. (Institute of Psychiatry, University of London, UK)

DeRUBEIS, R. J. (University of Pennsylvania, Philadelphia, PA, USA)

EIFERT, G. H. (West Virginia University, Morgantown, WV, USA

FOA, E. B. (Allegheny University of the Health Sciences, Philadelphia, PA, USA)

FONAGY, P. (University College London, UK)

FRAENKEL, P. (New York University, NY, USA)

FREEMAN, A. (Philadelphia College of Osteopathic Medicine, PA, USA)

FROST, R. O. (Smith College, Northampton, MA, USA)

HACKMANN, A. (University of Oxford, Warneford Hospital, UK)

HALFORD, W. K. (Griffith University, Nathan, Qld, Australia)

HEAP, M. (University of Sheffield, UK)

HEIMBERG, R. G. (Temple University, Philadelphia, PA, USA)

JANSEN, A. (Universiteit Maastricht, The Netherlands)

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JUSTER, H. R. (Pine Bush Mental Health, Albany, NY, USA)

LADOUCEUR, R. (Universit•aval, Qu c, PQ, Canada)

LEJUEZ, C. W. (West Virginia University, Morgantown, WV, USA)

LORION, R. P. (Ohio University, Athens, OH, USA)

LUDGATE, J. W. (Bristol Regional Medical Center, Bristol, TN, USA)

MARGRAF, J. (Technische Universit•Dresden, Germany)

MARKMAN, H. J. (University of Denver, CO, USA)

MERCKELBACH, H. (University of Maastricht, The Netherlands)

MUESER, K. T. (New Hampshire–Dartmouth Psychiatric Research Center, Concord, NH, USA)

MURIS, P. (University of Maastricht, The Netherlands

NEWMAN, M. G. (Pennsylvania State University, University Park, PA, USA)

PANTALON, M. V. (Yale University School of Medicine, New Haven, CT, USA)

PEERSON, S. (University of California, Santa Barbara, CA, USA)

6.02 Behavioral Approaches, Pages 25-49, Jürgen Margraf