Concurrent Parent and Child Therapy Groups for Externalizing Disorders: From the Laboratory to the World of Managed Care

W. Douglas Tynan, Penn State Geisinger Medical Center, and Wendy Schuman and Naomi Lampert, The George Washington University Children's National Medical Center

As managed care organizations move from cost cutting to cost-effective treatment, greater emphasis will be placed on utilization of documented, effective psychotherapies. Externalizing disorders in children, including attention-deficit disorder and oppositional-defiant disorder, comprise the most frequent referrals to outpatient clinics. Of available psychosocial treatments, parent training and child social-skills training have established efficacy in research settings. But in community settings, these approaches are not often systematically used, and rarely have they been shown to be effective. In a hospital-affiliated child psychiatry clinic located in a n upper-middle-class community, parent and child group programs were set up to be the standard initial treatment for these disorders for children ages 5 to 11. Using the Eyberg Checklist for pre- and post measures, 55 patients who completed treatment showed an average treatment effectiveness of 0.89 standard deviations on the intensity score, which is comparable to outcome data from research studies of efficacy. This would indicate that these programs have effectiveness in a standard clinic setting that is comparable to their efficacy in research intervention programs.



Modifying CBT to Treat Panic Disorder in Patients With Schizophrenia

Lynn F. Bufka and Stefan G. Hofmann, Boston University

Although individuals with schizophrenia often have other psychiatric conditions, such as panic disorder, less treatment attention is typically focused on this problem. Although established, efficacious cognitive behavioral treatments (CBT) exist, rarely have these interventions been used with individuals with schizophrenia. Our objective is to further improve the effectiveness (clinical utility) of an empirically validated treatment for panic disorder. Specific strategies are discussed regarding the modification of the treatment environment, the role of other providers, the establishment of rapport and the therapist-patient relationship when utilizing CBT for panic disorder with patients with schizophrenia. Furthermore, issues related to cultural differences, trauma history, and ethics are explored. Additionally, the treatment approach is outlined and the limitations of a standardized treatment intervention are discussed. Finally, a case example of a client with schizophrenia and panic disorder treated with a modified version of an empirically validated, cognitive behavioral protocol for panic disorder is offered to illustrate the points.



Use of Legal Drugs by Psychiatric Outpatients: Benefits, Costs, and Change

Kate B. Carey, Stephen A. Maisto, Michael P. Carey, Christopher M. Gordon, and Christopher J. Correia, Syracuse University

Caffeine, nicotine, and alcohol use by persons with a severe mental illness occurs frequently but is poorly understood. We used qualitative methods to elicit information regarding the functional relationships between legal substance use and its antecedents and consequences. This report summarizes responses provided by 37 psychiatric outpatients who participated in focus groups and key informant interviews regarding the use and functions of alcohol, caffeine, and nicotine. We describe major themes regarding positive and negative consequences, triggers for use, change efforts, and offer observations regarding substance use in this underserved population.



A Comprehensive Model for Behavioral Treatment of Trichotillomania

Charles S. Mansueto, Behavior Therapy Center of Greater Washington and Bowie State University, Ruth Goldfinger Golomb, Behavior Therapy Center of Greater Washington, and Amanda McCombs Thomas and Ruth M. Townsley Stemberger, Loyola College in Maryland

Trichotillomania is a disorder characterized by repetitive pulling out of one's hair. In this paper, we explore the essential elements for effective treatment and propose a comprehensive model for behavioral intervention. Individualized, focused treatment proceeds through 4 phases: First, a functional analysis is conducted that garners information about critical antecedents, behaviors, and consequences of hair pulling. Next, this information is organized into cognitive, affective, motoric, sensory, and environmental modalities. Then specific treatment strategies are selected and implemented to target critical maintaining factors through relevant modalities. Finally, evaluation and modifications are made as necessary. The potential advantages of this approach are discussed, as are its limitations.



The Sharing of Behavior Therapy: From Scientists and Practitioners to Communities and Consumers

Arthur Freeman, Philadelphia College of Osteopathic Medicine

The focus of the 1996 AABT conference was the sharing of behavior therapy. The issue addressed in many of the papers and posters of that conference was how information, change strategies, and treatment conceptualizations move from scientists to practitioners to the public or to consumers. This is by no means a linear communication. In some instances the public asks a question that the scientists are called upon to answer. In other cases, the point of origin of a question or issue is the clinical community. In the words of Walt Kelly's cartoon character of another era, Pogo, too often "We have met the enemy, and they is us." Often, the scientists and the practitioners are the same persons. While there is peace over the land, there are no fireworks. Other times there appears to be conflict over whether what we do as behavior therapists is more scientific or more clinical. Are we scientist/practitioners or practitioner/scholars? Should we be in the laboratory or in the public eye? Should we be talking to the public or should we only talk to each other?
What I would like to address in this paper are some of these questions. In my survey of several former AABT presidents, I asked them how they came up with the ideas for their presidential addresses. One said, "Cite some research." Another said, "Show some charts and tables." Another said, "Quote the literature." And another said, "Tell a story." While I would like to do all of these, I thought I could make my point best with a story. But then I didn't know what story to tell. So I went down to the deepest, darkest room in the basement archives of the AABT skyscraper in New York. I searched through dusty boxes and shelves, and in my search, I came across a manuscript, written in a language that I didn't know. At great expense and with great effort I had it translated and I want to share with you the contents of that manuscript as it contains a parable fitting for our time. It starts off as many stories do: "Once upon a time . . ."



The Case of Anna: A 26-Year-Old Woman With Major Depression and Borderline Personality Disorder

Willem Kuyken, University of Pennsylvania School of Medicine

This issue of Cognitive and Behavioral Practice presents a case conference of Anna, a 26-year-old woman with major depression and borderline personality disorder. The format for this case conference is the description of the assessment of Anna's presenting problems (this paper) and a series of response papers written by cognitive-behavioral therapists.



Targeting Core Beliefs in Treating Borderline Personality Disorder: A Response to the Case of Anna

Rebecca V. Fossel and Joseph H. Wright, University of Pennsylvania School of Medicine

The present response paper is one of a series describing various cognitive-behavioral approaches to treating a patient, Anna, who has been diagnosed with borderline personality disorder (BPD) and comorbid major depression (Kuyken, 1999). Anna is a 26-year-old, married, mother of two young children, who recently began a new job. Our case conceptualization focuses on the role of maladaptive core beliefs (A. T. Beck, Freeman, & Associates, 1990) and the avoidant/dependent subtype of BPD (Layden, Newman, Freeman, & Morse, 1993). Three stages of treatment are described (assessment/conceptualization, intervention, and maintenance) from a cognitive therapy perspective, and a cognitive case conceptualization diagram (J. S. Beck, 1995) is utilized to address three problems arising during therapy.



A Dialectical Behavior Therapy Perspective on the Case of Anna

Clive J. Robins, Duke University Medical Center

Dialectical behavior therapy (DBT) is a cognitive behavioral treatment designed specifically for individuals with borderline behaviors, particularly self-injurious and suicidal behaviors. In fact, currently it is the only psychosocial treatment for this population with published efficacy data from a randomized trial . My colleagues and I recently also reported superior outcomes across many areas of functioning for DBT compared to treatment as usual for borderline women veterans, demonstrating the transportability of this treatment. I appreciate this opportunity to present a DBT perspective on the case of Anna and look forward to the responses of others with somewhat different perspectives. My assumption is that all cognitive behavioral perspectives have more commonalities than differences; therefore, I will attempt to highlight the ways in which DBT may be different.



New Directions for Cognitive Therapy: A Schema-Focused Approach

Christine L. Ratto and Dante L. Capitano, University of Pennsylvania School of Medicine

Personality disorders are among the most difficult to treat and most frequently encountered problems presented to clinicians. When working with these individuals, it is imperative to have a sound conceptualization and thorough plan for treatment. The conceptualization and treatment plan for a 26-year-old female diagnosed with major depression and borderline personality disorder (BPD) is based on Jeffrey Young's model (1994), schema-focused therapy, an integration of cognitive therapy (CT) with gestalt and object relations techniques. It extends traditional CT developed by Beck, Rush, Shaw, and Emery (1979) by placing greater emphasis on the therapeutic relationship, affective experience, and the linking of early life experiences to present-day problems (Young). This model and treatment approach was developed for character disorders, including BPD, as these individuals often showed a less favorable response to traditional CT. Anna appears to be an appropriate patient for the use of this treatment approach, as she reports long-standing interpersonal problems, severe levels of depression and anxiety, and chronic feelings of emptiness and hopelessness. This paper will outline the schema-focused model of CT and demonstrate how this approach can be applied and tailored to Anna.



A Life of Quiet Desperation: The Case Example of Anna

J. Russell Ramsay, University of Pennsylvania

The purpose of this paper is to outline a course of treatment with Anna, a woman who presents for therapy with major depression and borderline personality disorder. A cognitive case conceptualization, influenced by constructivist theory and developed from the patient's background, is presented and utilized to guide treatment and to inform the clinical decision-making process. This conceptualization is also used to manage three problems that arise in the course of treatment.



A Developmental Psychopathology Approach: A Response to the Case of Anna

Willem Kuyken, University of Pennsylvania School of Medicine

This paper recounts my work with Anna, a 26-year-old married woman working in two part-time jobs, who presented with major depression. The high prevalence rates of depression, the comorbidity of depression with personality disorders (see Farmer & Nelson-Gray, 1990), and the long-term and destructive course of borderline personality disorder (BPD) present a formidable challenge both to mental health professionals and clinical researchers (A. T. Beck, Freeman, & Associates, 1990; Gunderson & Zanarini, 1987; Linehan, 1993; Ryle, Leighton, & Pollock, 1997). Two main themes will be emphasized. First, the last 10 years has seen a burgeoning of clinical accounts, theoretical expositions, and clinical research of comorbid depression and personality disorders in the cognitive-behavioral tradition. This paper seeks to draw on this literature in describing and explaining the case of Anna. Second, a developmental psychopathology cognitive-behavioral approach is adopted in conceptualization and treatment planning.



The Case of Anna: Addressing Three Special Problems in Treatment

Cory F. Newman, University of Pennsylvania School of Medicine

This summary paper uses the general case conceptualizations and interventions suggested by the previous authors on the case of Anna to construct methods by which to deal effectively with the three special problems that arose during the course of her treatment. Four general principles are explicated, including (1) maintaining and presenting a calm, warm, level-headed repertoire of responses under pressure, (2) conceptualizing the problem on the spot, (3) making use of adjunctive persons, including professional colleagues or people close to the client, and (4) having a set of clinical guidelines in place to help therapists navigate difficult terrain quickly, efficaciously, and with confidence. These principles serve to "ground" therapists as they attempt to think through and problem-solve difficult clinical scenarios with a high-risk client such as Anna. Sample dialogues are presented for each of the three situations in order to illustrate the recommended therapeutic processes.