ABSTRACTS

Entering the New Frontier of Managed Mental Health Care: Gold Mines and Land Mines

Kirk Strosahl, Group Health Cooperative of Puget Sound, Seattle, Washington

This article examines issues that behavior therapists must address as they adapt to the new and complex trends of managed mental health care. The origins of the managed health care movement are reviewed. Major shifts in clinical practice will occur in four primary areas: viewing both the client and payer as "customers," accepting accountability for clinical outcomes, providing efficient, empirically based care, and accepting the technical and ethical challenges of being both cost conscious and quality focused. Behaviorally trained clinicians and researchers will have many potential advantages working in the era of managed care. To capitalize on their background strengths, behavior therapists must learn to work with and not against managed care systems, learn the language necessary to have constructive, change-oriented dialogues with managed care executives, and learn to conduct "field based" research to answer important questions about the clinical efficacy and cost efficiency of behavioral interventions. Finally, the behaviorally trained clinician should try to find the right "fit" between practice style preferences and choice of managed care setting.



The Therapeutic Relationship in Cognitive-Behavioral Therapy: Patient Perceptions and Therapist Responses

Jesse H. Wright, University of Louisville School of Medicine, Louisville, Kentucky, and Denise Davis, Vanderbilt University School of Medicine and Vanderbilt School of Arts and Sciences, Nashville, Tennessee

A working relationship between the patient and therapist is an essential part of any psychotherapy, yet few guidelines exist for this component of cognitive behavioral treatment. Findings of therapy process and outcome research suggest that the therapeutic relationship strongly influences treatment results, and that interpersonal factors and technical applications interact in forming an effective alliance. Considering the perspective of the patient, we identify general expectations and individual differences that can have an impact on the therapeutic relationship. Individual differences are discussed in four areas of clinical interest: situational concerns; the effects of Axis I psychiatric disorders; sociocultural influences; and personality structure and schemas. Efforts to understand the patient's perspective, based on an analysis of general expectations and individual differences, can assist therapists in optimizing the relationship component of cognitive behavioral therapy.



Understanding Client Resistance: Methods for Enhancing Motivation to Change

Cory F. Newman, Center for Cognitive Therapy, University of Pennsylvania

Clients sometimes work in opposition to their therapists, a phenomenon known as "resistance." Such behavior is not simply an impediment to treatment, but also a potentially rich source of information about each client. This information can be assessed and utilized to strengthen the therapeutic relationship, help the therapist better understand the ideographic obstacles to change, and devise interventions that may motivate the client toward therapeutic activity and growth. Clinical vignettes of three resistant clients are presented, illustrating both the commonalities and unique factors that lead to resistance across cases. Eight important assessment questions and 10 suggested interventions are listed and discussed in detail. The practical applications of these methods in each of the three case studies shed light on how therapists can enhance their resistant clients' motivation for therapeutic change.



Emotional Awareness Training: A Prerequisite to Effective Cognitive-Behavioral Treatment of Borderline Personality Disorder

Joan M. Farrell and Ida A. Shaw, Indiana University School of Medicine, Indianapolis, IN

This paper describes a new approach to increasing emotional stability in patients with borderline personality disorder (BPD) through experiential exercises designed to increase their level of emotional awareness. This approach, called Emotional Awareness Training, is hypothesized to provide the groundwork for emotional stability in BPD patients and to be an important prerequisite to the effective use of cognitive and behavioral interventions with these patients. A comprehensive model for the treatment of BPD is described, which begins with emotional awareness training, followed by training in distress reduction and emotional regulation skills, and work on identifying and challenging early maladaptive cognitive schemas. A treatment manual for Emotional Awareness Training is available from the authors. The models for BPD treatment of Dialectical Behavior Therapy and Cognitive Therapy are reviewed and the issue of research to evaluate the effectiveness of cognitive-behavioral treatment is discussed.



Comorbidity of Addictive Behavior and Mental Disorder: Outpatient Practice Guidelines (for Those Who Prefer Not to Treat Addictive Behavior)

Arthur T. Horvath, La Jolla, California

Guidelines are presented for treating the patient with both addictive behavior (AB) and mental disorder (MD) who refuses referral to specialized AB treatment. These guidelines are based on a cognitive-behavioral therapy (CBT) model of AB. The CBT model avoids conflicts associated with providing a psychological treatment for MD and a disease model treatment for AB. Many CBT AB interventions can be provided by a psychotherapist who does not specialize in AB. These interventions may be sufficient treatment, or may motivate the patient to obtain specialized AB treatment.



Critical Issues in the Treatment of Anger

Raymond DiGiuseppe, St John's University and Institute for Rational Emotive Therapy, Raymond Tafrate, Hofstra University and Institute for Rational Emotive Therapy, and Christopher Eckhardt, Hofstra University

This article proposes that anger has received less attention in the behavior therapy literature than other emotional disorders. Little research exists to guide clinical practice on the effectiveness of interventions to treat anger. Suggestions are made for treating angry clients. These suggestions are presented as researchable hypotheses. It is proposed that angry clients often fail to establish a therapeutic alliance with their therapists. Failure to agree on the goal of changing their anger is the component of the alliance which is most problematic. Strategies to develop the therapeutic alliance with angry clients are proposed. Script theories of emotions are presented as an important tool for understanding clients' reluctance to change and in establishing the alliance with clients of different cultural backgrounds. The creation of new scripts that are acceptable to the client's cultural group is presented as one strategy to establish a therapeutic alliance. It is suggested that the use of exposure based treatment may be a promising treatment for anger.



Complexities and Lesser Known Aspects of Obsessive-Compulsive and Related Disorders

Fugen A. Neziroglu, Institute for Bio-Behavioral Therapy & Research, Great Neck, New York

Obsessive compulsive disorder (OCD) affects I out of 40 Americans (Robins et al., 1984). This means that approximately 5 million individuals will develop the disorder during their lifetime. Therefore, as a clinician, the likelihood of being asked to treat this disorder is very high. In addition, when one considers obsessive compulsive related disorders (e.g., body dysmorphic disorder, hypochondriasis, trichotillomania, Gilles de la Tourette syndrome) and obsessive compulsive behaviors observed in various conditions, the number of individuals affected is even greater. In approximately 27 years since the development of a behavioral treatment approach for OCD, many advances have occurred. In this paper, the assessment and behavioral treatment of obsessive compulsive and related disorders will be discussed. In addition, some conditions where obsessive compulsive behavior is common will be explored. Prognostic indicators such as the severity of the initial depression or anxiety and the strength of the belief in the obsession and its role in treatment outcome will be presented. Ways to overcome these barriers will be discussed.



Cognitive-Behavioral Treatment of Functional Somatic Syndromes: Integrating Gender Issues

Brenda B. Toner, Clarke Institute of Psychiatry and University of Toronto

This paper has two major aims: First, to discuss a cognitive-behavioral model, rationale, and empirical support for cognitive-behavioral therapy (CBT) for functional somatic syndromes, with an emphasis on irritable bowel syndrome (IBS); Second, to highlight the importance of integrating gender issues in CBT with IBS clients. It is argued that the following content areas require added focus in CBT because of their relevance in the lives of women who have received a diagnosis of IBS: history of physical and sexual abuse, gender role conflict, physical functioning, and relationship issues concerning nurturance, assertion and pleasing others. It is further argued that feminist principles are compatible with cognitive behavioral principles and can be readily incorporated in the practice of CBT to provide further emphasis on the social context.



SAEB: A Method of Conceptualization in the Treatment of Panic Attacks

Frank M. Dattilio, Center for Cognitive Therapy, University of Pennsylvania School of Medicine

This article introduces a system for conceptualizing panic attacks and illustrates with a case history how symptom induction and the proposed system for capturing the cognitions, emotions, and behaviors occurring during the panic can facilitate treatment. The system, named SAEB as an acronym for symptoms, automatic thoughts, emotion, and behavior, is a useful aid to guiding the patient first to recognize how certain emotions and cognitions serve to escalate the attack and then to substitute better coping cognitions and emotions. A discussion section addresses when the use of this intervention is most appropriate and provides a review of the steps to be taken when implementing this technique.