c&bp7.3

A Developmental Adaptation of Panic Control Treatment for Panic Disorder in Adolescence
Emily C. Hoffman and Sara G. Mattis, Center for Anxiety and Related Disorders at Boston University

Recent research indicates that panic disorder occurs in adolescence, often causing significant interference in daily life and activities that are essential to normal adolescent development. Although late adolescence has been suggested as the initial peak age of panic disorder onset, there is a paucity of research on the treatment of adolescent panic. Based on the well-established efficacy of cognitive-behavioral treatments of panic disorder in adults, particularly Panic Control Treatment (PCT), an adaptation of PCT was developed for the treatment of panic disorder in adolescents. Case studies are presented of two adolescents treated using the adapted PCT protocol. Following 11 individual treatment sessions, each adolescent experienced substantial reductions in frequency of panic attacks, fear and avoidance of agoraphobic situations, and scores on self-report measures of anxiety and anxiety sensitivity. Implications for the treatment of panic disorder in adolescence are discussed.

Behavioral Treatment of Obsessive-Compulsive Disorder in a Naturalistic Setting
Barbara Olasov Rothbaum and Fran Shahar, Emory University School of Medicine

This report describes a naturalistic study of an outpatient cognitive-behavioral treatment of obsessive-compulsive disorder (OCD). Treatment consisted of exposure and response prevention (ERP). Over the course of 7 years, 39 patients received a diagnosis of OCD and had a baseline Y-BOCS (Yale-Brown Obsessive-Compulsive Scale) score. Of those, 23 received treatment and completed a Y-BOCS following treatment. Y-BOCS scores fell from 24.3 at pretreatment to 7.9 at posttreatment for the 23 patients who received treatment. Results are discussed in the context of randomized clinical trials versus naturalistic applications. In addition, a case summary is presented highlighting some of the treatment issues in delivering ERP in an outpatient clinical setting.

Dual Focus Schema Therapy for Personality Disorders and Substance Dependence: Case Study Results
Samuel A. Ball, Yale University School of Medicine, and Jeffrey E. Young, Columbia University

We review the theory, techniques, and development of a manual-guided individual psychotherapy for substance-dependent individuals diagnosed with personality disorders. Dual Focus Schema Therapy (DFST) integrates relapse prevention for substance dependence with targeted work on early maladaptive schemas (enduring negative beliefs about oneself, others, and events) and coping styles. The first three patients (one each from DSM-IV Axis-II Cluster A, B, and C) treated during the pilot testing phase of the manual are summarized to illustrate differences in psychopathology, personality, and interpersonal functioning, early maladaptive schemas and coping styles, and treatment response.

The Use of Functional Assessment to Facilitate Treatment Adherence: A Case of a Child With HIV and Pill Refusal
Cynthia M. Anderson, Kenneth J. Ruggiero, and Christina D. Adams, West Virginia University

Inability or refusal to swallow medication is a serious problem for individuals with both chronic and acute illness. This and other forms of medication nonadherence are especially problematic for individuals diagnosed with human immunodeficiency virus (HIV), because medication is necessary to ward off the onset of other illnesses and to prolong life. We present the case of a 7-year-old boy with HIV and pill refusal. The purpose of this paper is twofold: (a) to illustrate the utility of a functional assessment to facilitate treatment for pill refusal in a boy diagnosed with HIV, and (b) to replicate other studies demonstrating the efficacy of stimulus-fading procedures.

The Importance of Cognitive Processes in Facilitating Accepting in Psychotherapy
Albert Ellis, Albert Ellis Institute

Hayes's (1994) Acceptance and Commitment Therapy emphasizes accepting but deemphasizes cognitive techniques of helping clients achieve it. This paper shows how Rational Emotive Behavior Therapy (REBT) also emphasizes accepting but, in addition to using experiential and behavioral techniques, stresses cognitive methods. REBT particularly shows people how to think about their thinking and thereby achieve full and lasting acceptance of themselves, other individuals, and the adversities of life.

Graduate Training for a Career in Behavioral Medicine: A Personal Account
Allison G. Snyder, Katy-West Houston OB/GYN Associates

The rapidly changing field of psychology dictates that trainees be prepared to adapt to evolving market demands for psychological services. Current graduate training fosters the development of many critical skills for successful integration into medical settings. Additional experiences not currently addressed in many programs may enhance the overall preparation of trainees for their careers. These issues are reviewed from the perspective of a recently licensed psychologist beginning a career in health psychology.

Special Series: Accentuating the Role of Therapist Emotion in Behavior Therapy Training

Introduction
Rachel Kimerling, University of California at San Francisco, San Francisco General Hospital

This special section is an assessment of issues surrounding therapist emotion in behavior therapy that began at a clinical roundtable presentation at the 1996 annual meeting of the Association for Advancement of Behavior Therapy. At this roundtable discussion, therapists, clinical supervisors, therapists in training, and researchers gathered to talk about conceptualizations of therapist emotions as they relate to the practice of psychotherapy. The substantial enthusiasm for a topic, which many felt was understudied within behavioral and cognitive behavioral frameworks, eventually led to this special issue. The resulting dialogue has focused on recognizing factors that maintain the lack of emphasis on therapist emotion in cognitive behavioral therapy, and on identifying potential points of intervention, particularly with respect to the training and supervision of new therapists. We feel that an emphasis on training is especially important for two reasons: First, new therapists experience some emotional responses which may be unique to the training role, and we feel that the most effective therapists are those with whom these responses are addressed in supervision. Second, addressing clinical, research, and training issues with therapists in training has potential to influence a new generation of behavior therapists, and therefore the field of behavior therapy, to develop a more comprehensive view regarding therapist emotion.

The Role of Emotion in Psychotherapy Supervision: A Contextual Behavioral Analysis
Victoria M. Follette, University of Nevada, Reno, and Sonja V. Batten, University of Nevada, Reno, & Medical University of South Carolina

While much has been written regarding the importance of emotional expression in psychotherapy, much less attention has been paid to the role of emotion in clinical supervision. Recently, several radical behavioral psychotherapies have been developed that may shed light on theoretical issues important to the expression of emotion in supervision. This paper describes the theoretical viewpoints of two such contextual therapies, Functional Analytic Psychotherapy (FAP) and Acceptance and Commitment Therapy (ACT), and applies the frameworks of these therapies to the process of clinical supervision.

Therapist Emotional Responses to Patients: Building a Learning-Based Language
Rachel E. Kimerling, University of California at San Francisco, San Francisco General Hospital
Antonette M. Zeiss and Robert A. Zeiss, VA Palo Alto Health Care System and Stanford University School of Medicine

In this paper we address the thesis that affective responses of the therapist in the therapist-patient interaction are common, and have potential to influence decision points in psychotherapy interventions. We discuss the importance of directly addressing these emotional responses, especially in the training of new cognitive behavioral therapists. We suggest a framework for conceptualizing emotional responses from a social learning theory perspective. This conceptualization highlights interactions between therapist, patient, and the psychotherapy context. We also propose a terminology for discussing therapist emotional reactions as nonpathological constructs and propose relevant guidelines for the supervision of therapists in training.

Researching Therapist Emotions and Countertransference
Lisa M. Najavits, Harvard Medical School and McLean Hospital

The study of therapist emotions is discussed with emphasis on its centrality to clinical practice and its relationship to countertransference. The paper describes dilemmas in researching therapist emotions (e.g., whether therapists can and will report their emotions; what emotions are), examples of key findings from research studies (e.g., therapist emotions vary based on patient diagnoses; therapist emotions cluster into meaningful categories), and eight suggestions to improve future research (e.g., relate therapist emotions to real-life clinical phenomena; do not assume an emotion is "positive" or "negative"). The study of therapist emotions is concluded to be a fruitful area of research that needs refinement in theory and methods in order to improve on more simplistic prior studies.

Therapeutic Burnout Among Borderline Personality Disordered Clients and Their Therapists: Development and Evaluation of Two Adaptations of the Maslach Burnout Inventory
Marsha M. Linehan, Bryan N. Cochran, Corinne M. Mar, Eric R. Levensky, and Katherine Anne Comtois, University of Washington

Providers of psychotherapy services are likely to become emotionally exhausted, to depersonalize their clients, and to have diminished personal accomplishment as a consequence of treating ?difficult? clients. This pattern, termed burnout, has recently received considerable empirical attention. Whereas previous researchers have explored burnout as an occupational phenomenon, we propose that both therapists and clients experience burnout reciprocally; that is, both providers and recipients can become burned out from the therapy process. We administered a modified client version of the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1986) to clients receiving psychosocial treatment for borderline personality disorder (BPD) both prior to therapy and 4 months into treatment and a modified therapist version of the MBI to their therapists. We predicted that client difficulty (depression, anger, and suicidality) would be related to therapist burnout, and that high expectancies of therapy would be related to increased burnout for both clients and therapists at 4 months. Whereas the first prediction was not supported, we did find some support for the relationship between expectancies and burnout. Post-hoc analyses also revealed an interesting pattern: The most reliable predictor of therapist burnout at 4 months was client burnout at pretreatment. Implications of this interaction between client burnout and the therapists? responses are discussed.

Clinical Decision Making in Behavioral Supervision: ". . . And How Does That Make You Feel?"
Arthur M. Nezu, Rima Saad, and Christine Maguth Nezu, MCP Hahnemann University

This article describes the application of a problem-solving model to the process of supervision, specifically focusing on the issue of problems related to discussions of emotional reactions to patients. The problem-solving model encompasses five key processes: problem orientation, problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification. To illustrate this process, a beginning supervisor applies the model to her supervision of a student therapist working with chronically ill patients.

Response: The Role of Emotion in Cognitive Therapy, Cognitive Therapists, and Supervision
Christine E. Reilly, University of Delaware

It is a myth that cognitive therapy does not address emotions. In fact, emotion is a primary variable in the cognitive model. The cognitive therapist facilitates identification of troubling emotions, helps the patient explore the origins of the emotion (automatic thoughts), and collaboratively generates alternative perspectives. Cognitive therapy supervisors help trainees learn to identify their own automatic thoughts and emotions and teach them how to use this information productively in therapy. This manuscript addresses these issues and includes some supervisory strategies for addressing therapists' emotions when these emotions interfere with the delivery of cognitive therapy.

Cognitive Behavioral Case Conference

The Case of Ryan: A Child Who Suffered Multiple Episodes of Sexual Abuse
Esther Deblinger, University of Medicine & Dentistry of New Jersey-School of Osteopathic Medicine
Diane M. Hall, University of Pennsylvania

The case of Ryan presents the history of a 12-year-old male who was sexually abused on multiple occasions, first by his biological father at 6 years of age and later by a female cousin. The child, no longer in contact with his biological father, is accompanied to the initial assessment sessions by his biological mother and stepfather. Ryan reports symptoms of posttraumatic stress and depression, and he exhibits behavioral difficulties, including age-inappropriate sexual behaviors both at home and at school. The response papers that follow this case presentation suggest assessment and treatment plans that reflect the diverse theoretical leanings of the respondents. These clinicians describe how they might design assessment and treatment plans that integrate cognitive-behavioral approaches with ideas and interventions derived from other theoretical orientations including humanistic, family systems, and psychodynamic models.

Response Paper: Integrating Cognitive Behavioral Therapy Into a Psychodynamic Framework
Amy L. Hoch-Espada, University of Medicine & Dentistry of New Jersey-School of Osteopathic Medicine
Julie Lippmann, University of Medicine & Dentistry of New Jersey-School of Osteopathic Medicine

The following case response seeks to integrate psychodynamic theory, cognitive-behavioral, and other interventions to provide an inclusive and holistic approach to the treatment of a 12-year-old male victim of sexual abuse. The case is complex in that it involves an adolescent with significant symptoms secondary to sexual abuse, including depression, suicidal ideation, posttraumatic stress disorder, dissociation, and sexually reactive behaviors. A psychodynamic conceptualization of the case offers insight into the therapeutic relationship and transference and countertransference issues; cognitive-behavioral theory and interventions are presented to address dysfunctional thoughts and problematic behaviors. Additional approaches to treatment and assessment are mentioned as means of providing sexual-abuse-specific treatment within a psychodynamic framework. Adjunctive interventions with parents and school staff are also addressed.

Response Paper: Integrating Cognitive Behavioral and Humanistic Approaches
Anthony P. Mannarino and Judith A. Cohen, MCP-Hahnemann University-School of Medicine

This response to the case of Ryan integrates the basic elements of a humanistic approach with trauma-focused cognitive behavior therapy (CBT). Within a humanistic perspective, a trusting therapeutic relationship, a safe and secure therapeutic environment, and unconditional positive regard and respect from the therapist are emphasized as important factors in contributing to a positive outcome for a child sexual abuse victim and his family. Additionally, a number of CBT interventions are reviewed, including psychoeducation and behavioral contingencies related to inappropriate sexual behaviors, cognitive reframing for both the child and parents to address self-blame for the abuse and other inappropriate attributions and distorted cognitions, gradual exposure for the child, and behavior management with parents. Family treatment is also described in terms of its importance in helping Ryan and his family recover from the sexual abuse trauma and other related events.

Response Paper: Integration of Family and Cognitive Behavioral Therapy for Treating Sexually Abused Children: The Case of Ryan
Jan Faust, Nova Southeastern University

This paper demonstrates the application and integration of family systems therapy and cognitive behavioral therapy for the treatment of symptomatic children with histories of sexual abuse. This is achieved via the case of Ryan, a 12-year-old boy who had been sexually abused by two family members and who was experiencing affective/anxiety symptoms and acting-out behavior problems. While this paper provides a theoretical rationale and comprehensive treatment plan, additional details of specific treatment interventions, from both treatment modalities, are delineated. From the family systems perspective, an emphasis is placed upon the discussion of realignment of family structure and changing familial communication patterns (including messages about safety, protection, and validation of children's experiences). From the cognitive behavioral paradigm, exposure therapy and cognitive restructuring are accentuated. Finally, the importance of the integration of both modalities without violating the theoretical assumptions of either is highlighted.