ABSTRACTS

Clinical Decision Making in Everyday Practice: The Science in the Art

Christine Maguth Nezu, Arthur M. Nezu, Medical College of Pennsylvania & Hahnemann University

Despite a growing literature base documenting the efficacy of behavioral interventions, the everyday practitioner is faced with the demands of processing and translating a complex set of clinical information in order to make effective and ethical decisions. In this article, we present a model of decision making geared to increase the contribution of the scientific process to the art of clinical practice. This model is based upon a problem-solving framework that provides a practical heuristic guide for the generation and evaluation of solutions to everyday clinical problems.



Cognitive Therapy for Trauma-Related Guilt: Conceptual Bases and Treatment Outlines

Edward S. Kubany and Frederick P. Manke, Department of Veterans Affairs, Honolulu, Hawaii, University of Hawaii

There is consistent agreement that guilt has both affective and cognitive dimensions. We describe a conceptualization of event-related guilt in which cognitive elements play a crucial role. Factors posited as primary cognitive components or determinants of guilt include perceived wrongdoing, acceptance of responsibility, perceived lack of justification, and false beliefs about preoutcome knowledge caused by hindsight bias. Each cognitive component can be manifested as an irrational belief or faulty conclusion that can vary in magnitude. Numerous errors of logic that can lead trauma victims to draw faulty conclusions about their role in traumatic events are identified. Within the proposed model, correcting these thinking errors is considered the best way to alleviate guilt and is the primary task of cognitive therapy for trauma-related guilt (CT-TRG). With each guilt issue, a debriefing/imaginal exposure exercise precedes cognitive therapy. CT-TRG proper involves considerable psychoeducation and collaborative examination of each guilt component. Procedures are described for teaching clients to distinguish what they knew "then" from what they know "now" and to reassess perceptions of responsibility, justification, and wrongdoing in light of beliefs held and knowledge possessed when the trauma occurred. Several issues regarding applicability of the treatment model are discussed.



Treating Incest-Related PTSD and Pathogenic Schemas Through Imaginal Exposure and Rescripting

Mervin R. Smucker, Medical College of Wisconsin, and Jan Niederee, University of Pennsylvania

The prevalence of posttraumatic stress disorder (PTSD) among adult survivors of childhood sexual abuse indicates a need for the development of effective therapeutic interventions. This article presents one such treatment, Imagery Rescripting, that combines imaginal exposure with mastery imagery. Imagery Rescripting is based on an expanded information processing model that conceptualizes the recurring traumatic memories of the abuse survivor both within a PTSD framework and as part of the patient's core schemata. A rationale for the model is provided by a review of relevant information processing theories of PTSD and a discussion of the effects of sexual trauma upon schema formation. The treatment procedure is briefly described, results of a pilot study supporting the efficacy of Imagery Rescripting are cited, and its application is illustrated by means of a case study. It is proposed that Imagery Rescripting facilitates adaptive processing of childhood traumas by reducing intrusive PTSD symptoms and modifying abuse-related beliefs and schemas



Clinical Issues in Treating Children with Anxiety and Phobic Disorders

Wendy K. Silverman, Golda S. Ginsburg, and William M. Kurtines, Florida International University

Issues involved in conducting cognitive behavioral treatment with children who present with anxiety and phobic disorders are discussed. The rationale for using cognitive behavioral treatment procedures is based on our premise that effective, long-term child behavior change depends on an adequate "transfer of control" from therapist to parent to child. The treatment involves separate and conjoint child and parent sessions and is implemented in three phases: education, application, and relapse prevention. Specific treatment strategies, common obstacles to implementing these strategies, and suggestions to address these obstacles are described for each phase of the treatment. A case vignette illustrates some of the treatment issues discussed.



Expanding the Contextual Analysis of Clinical Problems

Mary M. Bandura and Carol Goldman, Boston, MA

One source of failure in behavior therapy is neglect and/or insufficient assessment of the social context that influences a problem. In this paper, we draw upon concepts and tools from family therapy to broaden the functional analysis of problems. We discuss how the analysis of family interaction sequences surrounding symptomatic behavior and the exploration of intergenerational material can illuminate the problem-solving role symptoms may serve in managing a family dilemma. By reframing symptoms in light of their beneficial social functions, the therapist may reconceptualize the client's problem and target relevant interaction patterns in designing interventions. Further, an expanded contextual analysis allows the therapist to more fully appreciate and utilize reasons why clients may have difficulty changing during the therapeutic process. This helps the therapist to time and structure compliance- based interventions more sensitively, and avoid negative attributions for noncompliance.



The Nature of Body Dysmorphic Disorder and Treatment With Cognitive Behavior Therapy

James C. Rosen, University of Vermont

Body Dysmorphic Disorder (BDD) is a distressing and disabling body image disorder that involves excessive preoccupation with physical appearance in a normal appearing person. Persons with BDD exhibit fears of being noticed, feelings of shame and embarrassment, thought processes that can range from repetitive thinking to delusions, avoidance of social situations and exposure of physical appearance, compulsive rituals, somatic preoccupation, medical and cosmetic treatment seeking, and resistance to psychological intervention. BDD overlaps diagnostically with other disorders and presents unique challenges for the mental health practitioner. The purpose of this paper is to describe the pathology of BDD and its development and treatment, although empirical information on these topics is very limited at the present time. Detailed recommendations are given for cognitive behavior therapy. Intervention consists of cognitive restructuring of private body talk and undue importance given to physical appearance, exposure to avoided body image situations, and response prevention of body checking and grooming behaviors.



Cognitive Therapy for Premenstrual Syndrome

Fiona Blake, John Radcliffe Hospital, Oxford

Premenstrual Syndrome (PMS) has been a subject of great interest in the last few years and has attracted many theories and treatments. Most of these focus on physical disturbance or imbalance. Less work has been done on psychological mechanisms associated with PMS. A cognitive model is described that considers a broad range of factors that contribute to those premenstrual affective changes associated with Late Luteal Phase Dysphoric Disorder (LLPDD) now called Premenstrual Dysphoric Disorder (PMDD). It is proposed that the cognitive appraisal of premenstrual changes in the context of a woman's current circumstances and personal assumptions determines whether she perceives them as distressing or as a normal and manageable part of her life. Vicious circles of negative thinking magnify the symptoms and increase anxiety, irritability, and low mood. Cognitive therapy gives a sufferer of PMS the opportunity to review her responses and to experiment with more adaptive thoughts and behavior. The process of therapy is described. This method was developed in the course of a treatment study for women with PMS. The treated group had significant relief of premenstrual symptoms.



When and How to Do Longer Term Therapy ... Without Feeling Guilty

Lata K. McGinn, Albert Einstein College of Medicine, Jeffrey E. Young, Cognitive Therapy Centers of New York and Fairfield County, CT, Columbia University, and William C. Sanderson, Albert Einstein College of Medicine

Although short-term cognitive behavior therapies (CBT) are widely effective, we have noticed that patients with personality disorders do not make sufficient progress with these treatments. We contend that optimal treatment can only be accomplished for these patients if it is modified to address the personality disorder. Schema-focused therapy (SFT) was developed by Young (1990) to specifically address the needs of these patients and combines cognitive, behavioral, interpersonal, and experiential techniques in treatment. Compared to short-term cognitive therapy (CT), SFT emphasizes the therapeutic relationship as a vehicle of change, utilizes emotive techniques to address early issues and later life problems, involves less guided discovery, more active confrontation of cognition and behavior patterns, and a greater concern with identifying and overcoming cognitive and behavioral avoidance. Finally, because there is far more resistance to change, the course of treatment is longer in SFT. Assessment, treatment strategies, and an illustrative case example will be provided in the present paper.



Use and Effectiveness of Self-Help Books in the Practice of Cognitive and Behavioral Therapy

Michael V. Pantalon, St. Barnabas Hospital, Hofstra University, Barry S. Lubetkin and Steven T. Fishman, Institute for Behavior Therapy, New York

Despite the limited, albeit positive, evidence of the efficacy of self-help books (SHBs), they are widely prescribed to patients by therapists. It appears that this is due in part to their great appeal to the general public. Based upon the available empirical studies, it appears that some SHBs are effective in changing problematic behaviors when used alone and when used in conjunction with therapy. In this article, the case is made for a SHB plus cognitive behavioral therapy as being more useful in some cases than a SHB alone, because the combination addresses the crucial and frequently cited issue of compliance with the directives of the treatment regimen in a SHB (Rosen, 1987). We offer recommendations for selecting and assigning SHBs that we believe are beneficial.