CONTENTS
 The Treatment Rationale in Cognitive Behavioral Therapy: Psychological Mechanisms and Clinical Guidelines
Michael E. Addis and Kelly M. Carpenter
Modular Cognitive-Behavioral Therapy: Dismantling Validated Treatment Programs Into Self-Standing Treatment Plan Objectives
David L. Van Brunt
Stories and Metaphors in Cognitive-Behavior Therapy
Michael W. Otto
Imagery Rescripting for Recurrent, Distressing Images
Mark D. Rusch, Brad K. Grunert, Robert A. Mendelsohn, and Mervin R. Smucker
Analysis of Behavioral Skills Utilized by Suicidal Adolescents Receiving Dialectical Behavior Therapy
Alec L. Miller, Sharon E. Wyman, Jonathan D. Huppert, Samantha L. Glassman, and Jill H. Rathus
Supervisor and Intern Perspectives on Supervision
Jill Bond Caire, Kristen Valus, and Ellie Dwyer
Introducing Behavior Therapy Into a Disease-Model Dual-Diagnosis Treatment Program
Deborah H. A. Van Horn
SPECIAL SERIES
COUPLES AND ILLNESS: INTEGRATING THE MEDICAL
AND PSYCHOLOGICAL PERSPECTIVES
COGNITIVE BEHAVIORAL CASE CONFERENCE
ABSTRACTS
The Treatment Rationale in Cognitive Behavioral Therapy: Psychological Mechanisms and Clinical Guidelines
Michael E. Addis and Kelly M. Carpenter, Clark University
Clinical experience and an accumulating body of research suggest that clients who enthusiastically buy into a cognitive-behavioral treatment (CBT) rationale show more favorable outcomes. But how should a therapist present and discuss a CBT rationale effectively? How does one respond to client concerns and doubts? What are the psychological processes operating when discussing why a client is suffering and what to do about it? We suggest that the treatment rationale is a considerably more subtle and complex process than has previously been assumed. It involves generating expectations, negotiating control and assigning blame, and its function may vary depending on the stage of treatment. We illustrate these points by considering common reactions to a CBT rationale and alternative therapist responses. We conclude that much closer attention should be paid to the treatment rationale in the context of research and clinical practice.
Modular Cognitive-Behavioral Therapy: Dismantling Validated Treatment Programs Into Self-Standing Treatment Plan Objectives
David L. Van Brunt, Offutt Air Force Base
A novel approach to using empirically supported treatment approaches in a managed care setting is discussed from an administrative perspective. A military mental health clinic adapted a skill-based group cognitive behavior therapy curriculum by dismantling empirically supported group treatment programs into free-standing modular components. Treatment plans are prescribed by combining desired treatment components in accordance with specific treatment objectives. Modules are assigned uniquely for each client and can be used either alone or in conjunction with individual therapy. The result is cost-effective and individualized mental health care that is both efficacious and time limited. Clinical, research, and administrative implications are discussed.
Stories and Metaphors in Cognitive-Behavior Therapy
Michael W. Otto, Massachusetts General Hospital & Harvard Medical School
The use of stories and metaphors in cognitive-behavior therapy provides a method to enhance information processing in sessions and thereafter. The goal is to help transform therapeutic information into a form that is easy to remember, provides useful guidance, and can be applied in relevant moments in a patient's life. The purpose of this article is to exemplify commonsense strategies, including vivid stories and metaphors, to help patients translate session material into behavior change.
Imagery Rescripting for Recurrent, Distressing Images
Mark D. Rusch and Brad K. Grunert, Medical College of Wisconsin, Robert A. Mendelsohn, University of Wisconsin–Green Bay, and Mervin R. Smucker, Medical College of Wisconsin and Cognitive Therapy Institute of Milwaukee
Intrusive images are a familiar aspect of daily experience that, when persistent and unwanted, may cause emotional distress. In many cases, images accompany disturbing and repetitive thoughts and ruminations. In others, images are the primary mental experience. This article describes the use of a therapy procedure—imagery rescripting (IR)—in the treatment of distressing intrusive images that occur spontaneously but are not memories of actual events or experiences (i.e., flashbacks, intrusive memories). Eleven individuals who reported recent onset of such images, and who did not benefit from brief treatment with imaginal exposure, subsequently improved significantly with one trial of IR. Subjective Units of Discomfort (SUDS) data and two case studies are presented. Results support the use of IR in the treatment of repetitive, distressing images that persisted despite previous personal efforts (distraction, reasoning) and clinical intervention with imaginal exposure.
Analysis of Behavioral Skills Utilized by Suicidal Adolescents Receiving Dialectical Behavior Therapy
Alec L. Miller, Montefiore Medical Center, Albert Einstein College of Medicine, Sharon E. Wyman, New York, Foundling Medical Center for Pediatrics and Rehabilitation, Jonathan D. Huppert, New York Presbyterian Hospital, Samantha L. Glassman, Albert Einstein College of Medicine, and Jill H. Rathus, Long Island University, C.W. Post Campus
Researchers are currently applying dialectical behavior therapy (DBT), originally developed for adult chronically parasuicidal women diagnosed with borderline personality disorder (BPD), to a suicidal adolescent population diagnosed with BPD or borderline features. The four characteristic problem areas often found among these multiproblem patients are (a) confusion about self, (b) impulsivity, (c) emotional instability, and (d) interpersonal problems. DBT employs four corresponding behavioral skills modules aimed at increasing adaptive behaviors while simultaneously reducing maladaptive behaviors. The four skill modules include mindfulness skills, distress tolerance skills, emotion-regulation skills, and interpersonal effectiveness skills. The present study examines adolescent self-report of the helpfulness and overall effectiveness of these skills by using pre- and posttreatment evaluations. Consistent with prior research of DBT with adolescents, this study found significant reductions in BPD symptoms in all four problem areas. The four most highly rated skills included distress tolerance and mindfulness skills. Relationships found between the helpfulness of specific skills and improvement in particular problem areas are described. Lastly, implications for future research of DBT skill comprehension and application among adolescents are discussed.
Supervisor and Intern Perspectives on Supervision
Jill Bond Caire, Fielding Institute, and Kristen Valus and Ellie Dwyer, San Francisco General Psychosocial Medicine Clinic
This article explores the process of supervision by presenting a complex case from both the intern and the supervisor's point of view. The primary supervisor describes the clues that led her to advise the intern to explore an alternate diagnosis and how she addressed the problems of contradictory advice. A secondary supervisor describes her interim supervision with the intern. Finally, the intern describes her perception of the case, how it altered during the course of treatment, and how she resolved the issues of contradictory advice regarding the treatment. At the conclusion of the article, suggestions are made to increase the effectiveness of supervision in today's multidisciplinary settings.
Introducing Behavior Therapy Into a Disease-Model Dual-Diagnosis Treatment Program
Deborah H. A. Van Horn, University of Pennsylvania Health System
Rates of alcohol and drug abuse among individuals seeking psychiatric treatment exceed those of the general population, and there has been increasing attention to meeting the treatment needs of such dually diagnosed persons. Social-skills training shows promise as one aspect of integrated treatment for dually diagnosed inpatients, but poses practical questions of implementing behavior therapy in settings where a disease model of addictive behavior and psychopathology dominates. A case is made for integration of behavior therapy within the prevailing medical model, and supported by the author's experience providing skills training groups for inpatients. Clinical techniques for providing social skills training to patients with severe, heterogeneous presenting problems in the context of ever-briefer hospitalizations are described, as are means for increasing the value of the behavioral approach in a medical-model setting.
SPECIAL SERIES
COUPLES AND ILLNESS: INTEGRATING THE MEDICAL
AND PSYCHOLOGICAL PERSPECTIVES
Introduction
Tamara Goldman Sher, Illinois Institute of Technology
These papers and the response to these papers provided by Kettlewell (2000) highlight the importance of looking at medical conditions from a couples perspective and then provide the means to do so. These papers contribute to the growing body of literature that fills the gap between understanding the importance of an intimate relationship on health and illness and the notion that not all relationships are created equal in their protective qualities. That is, the papers that follow highlight a need for health care professionals to take a couples perspective on health care, and provide guidelines for how to assess and treat a couple, as well as how to use an intimate relationship to facilitate medical treatment.
Psychological Treatment of Couples Undergoing Fertility Treatment
Jennifer B. Levin and Tamara Goldman Sher, Illinois Institute of Technology
This article addresses a number of questions directly relevant to clinicians working with infertility patients. Issues addressed include a review of the impact of moderating variables on psychological adjustment; how to identify whether an individual or couple is experiencing psychological or marital distress that warrants treatment; whether to treat the individual or the couple; and what treatment interventions are appropriate for a given individual or couple.
Coronary Heart Disease: Intervention for Intimate Relationship Issues
Lynn A. Rankin-Esquer and Allison K. Deeter, Pepperdine University, Erika Froelicher, University of California–San Francisco, and C. Barr Taylor, Stanford University Medical School
Given that coronary heart disease (CHD) is the leading cause of death in the United States, continuing research on reduction of incidence as well as recovery from a cardiac event is critical. There are multiple risk factors for the development of, and recovery from, a cardiac event, including both physical (e.g., high cholesterol) and psychosocial (e.g., depression, social support). For a number of years the role of social support has been a focus of research, with the conclusion that social support is an important aspect of both the prevention of CHD as well as recovery from a cardiac event. An intimate relationship is obviously a potentially crucial source of social support, and thus the role of an intimate relationship in preventing or aiding in recovery from a cardiac event is explored in the current paper. Clearly there are a number of ways in which an intimate relationship can aid in the recovery of cardiac patients (e.g., emotional support, support for quitting smoking, starting or maintaining exercise program, treatment adherence). In addition, it is likely that a discordant intimate relationship may hinder the recovery of cardiac patients (e.g., social isolation, high conflict, etc.). Thus, interventions for cardiac patients that are focused on couple functioning are likely to be quite useful, both in terms of helping the relationship serve as a source of support, as well as in assuring that the relationship does not serve as an additional source of stress. Specific treatment recommendations are made for cardiac patient interventions that are couple focused.
Series Response: Do Psychological Interventions Make a Difference?
Paul W. Kettlewell, Penn State Geisinger Medical Center
A major challenge for the science of clinical psychology is to convincingly demonstrate the effectiveness of our interventions. Competition from pharmacological companies and restrictions by health insurance organizations make this an important challenge. Factors external to psychology as well as those within our profession contribute to the lack of full acceptance of psychological interventions. We need to identify psychological variables that have powerful relationships with health characteristics as well as investing in treatment outcome studies. Professional psychology also needs to commit to disseminating information about empirically supported treatments.
The Case of Mike: A Socially Rejected Adolescent in Residential Care
Kurt A. Freeman and Douglas W. Woods, Father Flanagan's Boys' Home
We present the case of Mike, a 13-year-old Caucasian male currently receiving services at a residential treatment facility (Boys Town). Mike has a history of significant behavior problems and experiencing a chaotic living environment, resulting in multiple out-of-home placements and eventually in him being made a ward of the state. Records indicate that various care providers have diagnosed Mike with Attention Deficit/Hyperactivity Disorder, Conduct Disorder, and Intermittent Explosive Disorder. Behavioral concerns at the time of referral for psychological services included significant social isolation from and rejection by peers, extreme social awkwardness, socially inappropriate behavior, and sexualized behavior (e.g., making lewd comments to females). Mike displays little to no insight as to either the presence or cause of his referral behaviors.
Response Paper:
Profound Social-Skills Deficit and a 6-Point Plan
Patrick C. Fiman, University of Nevada, Reno
This brief comment presents my clinical interpretation of the problems presented by Mike, a 13-year-old Caucasian male living at Boys Town, as described in his case description. My perspective on the case is behavior analytic, and my interpretation is that it involves profound social-skills deficits. To begin, I recommend a comprehensive functional assessment including an interview with Mike. Cautiously, in lieu of information from that assessment, I recommend a 6-point treatment plan including a carefully selected therapist, two types of positive peer reporting, a group approach to social-skills training, and staged and unstaged practice of target social skills.
Reponse Paper
Harnessing Environmental Contingencies to Enhance Social Skills: The Case of Mike J.
Lisa W. Coyne, Leigh Anne Faul, and Alan M. Gross, University of Mississippi
This article presents a clinical case conceptualization and possible treatment plan for a 13-year-old Caucasian male currently residing at the Boys Town treatment facility. The youngster's presenting problems are conceptualized using a behavioral/cognitive-behavioral model. An assessment plan employing functional analyses of behavior, as well as data gathered from rating scales and self-report instruments, is recommended to evaluate the presence and nature of the youth's behavior problems (social-skills deficits, potential attentional problems, and anxiety). An intervention based on a contextualized framework of social-skills assessment, treatment, and generalization is suggested, and adjunctive interventions for unique features of the case are offered. Potential problems of comorbidity and failure to generalize are discussed, and realistic expectations for outcome addressed.
Response Paper
Behavioral Skills Training to Remediate Deviant Social Behavior of an Adolescent in Residential Treatment
Raymond G. Miltenberger, North Dakota State University
This case conference paper describes a treatment plan for Mike, an intellectually limited 13-year-old boy with social-skill deficits and social behavior problems who resides in a family-style residential treatment program. Treatment would involve initial training with videotape vignettes for Mike to learn to identify appropriate and inappropriate social behaviors across a variety of typical social situations with peers. Following initial discrimination training, behavioral skills training procedures involving instructions, modeling, rehearsal, praise, and feedback would be implemented with peers in simulated social interactions. Training would include multiple exemplars and would continue until Mike had learned appropriate social behaviors for a wide range of social situations and had exhibited those behaviors in the residential and school sittings. Behavioral contingencies would also be implemented by staff for Mike's appropriate and inappropriate social behaviors in the residential and school settings to promote generalization.
Response Paper
Making Social Competence a Habit
Cynthia M. Anderson and Keith D. Allen, Munroe-Meyer Institute for Genetics and Rehabilitation & University of Nebraska Medical Center
We took a decidedly behavioral approach to solving this problem involving adolescent social-skills deficits. Following a functional assessment of both skill deficits and environmental contingencies, we would address the social problems presented in this case as if they were a persistent habit. Treatment would incorporate elements of simplified habit reversal technology, an empirically supported package of techniques for treating persistent habits. After teaching the client to detect, describe, and self-monitor each of the relevant aspects of both appropriate and inappropriate social behaviors, both natural and artificial supporting contingencies would be arranged to reach new or strengthen existing replacement behaviors in appropriate contexts.
Summary
The Case of Mike: Synthesis of Responses
Kurt A. Freeman and Douglas W. Woods, Father Flanagan's Boys' Home
We conclude this case conference by describing the similarities and differences between the respondents' comments. Regarding similarities, we highlight the focus on the contextual approaches to assessment and treatment of the referral concerns, the limited reliance on psychodiagnostic information for treatment development, the minimal attention paid to Mike's potential history of sexual abuse, and the scientist-practitioner nature of the recommendations. Differences noted are more limited and include the attention paid to the use of standardized assessment approaches, and the importance of social anxiety as a response pattern of concern.
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