c&bp8.2

Integrating DBT-Based Techniques and Concepts to Facilitate Exposure Treatment for PTSD
Carolyn Black Becker, Trinity University, and Claudia Zayfert, Dartmouth Medical School

While considerable evidence supports the use of exposure-based treatment for PTSD, its utilization in clinical practice remains limited. This article presents a systematic and empirically grounded approach to the flexible application of PTSD treatment research in a "true" clinical setting. High rates of attrition, suicidality, dissociation, destructive impulsivity, and chaotic life problems are reasons cited by clinicians for abandoning empirically supported exposure treatment. Linehan's dialectical behavior therapy (DBT), designed to address many of these issues, offers useful strategies for addressing the needs of patients considered poor candidates for exposure therapy. This article offers a model for integrating DBT-based theory, concepts, and skills with manualized exposure-based cognitive-behavior therapy for PTSD in order to improve patient (and therapist) tolerance of this treatment.

A Family-School Homework Intervention Program for Children With Attention-Deficit/Hyperactivity Disorder
Dina F. Habboushe, Sheeba Daniel-Crotty, James L. Karustis, Stephen S. Leff, Tracy E. Costigan, Suzanne G. Goldstein, Ricardo Eiraldi, and Thomas J. Power, Children's Hospital of Philadelphia/University of Pennsylvania School of Medicine

Children with attention-deficit/hyperactivity disorder (ADHD) typically have multiple problems with homework performance that may contribute to academic skills deficits and underachievement. Specialized interventions to address the homework problems of children with ADHD is greatly needed. A brief family-school training program to address the homework problems of children with ADHD is described. The Homework Success Program (HSP) involves group parent training in cognitive and behavioral principles and strategies that have empirical support in the literature. This program involves increasing parent understanding of their child's behavior and training in behavioral techniques to improve academic productivity and behavioral functioning. In addition, an emphasis is placed on improving goal-setting skills and increasing parent-teacher collaboration to address homework problems. Procedures for incorporating children into the intervention program are also included. Suggestions are made for assessing progress and outcomes in academic and behavioral functioning and parent-child interactions. Case illustrations are presented to demonstrate methods that may be useful in evaluating program effectiveness and to describe the types of outcomes that may occur when this program is implemented. Future research directions and suggestions for implementing this program in community and school settings are discussed.

Cognitive-Behavioral Strategies for Improving Medication Adherence in Patients With Bipolar Disorder
Elizabeth Brondolo, St. John's University, and Francis Mas, New York University Medical School

Bipolar disorder can have serious effects on patients' social and occupational functioning. Effective pharmacotherapies are available, but many patients have difficulties adhering to prescribed regimens. This paper presents a cognitive-behavioral program designed to improve medication adherence. The program focuses on three goals: prevention of suicide, stabilization of mood, and achievement of individual personal and occupational goals. The treatment consists of behavioral, cognitive, and interpersonal interventions. Behavioral interventions include goal setting, task analysis, and self-monitoring. These interventions provide the framework for therapy and include methods for evaluating the effectiveness of the pharmacological treatment. Cognitive interventions are directed at the shame, defensiveness, and fear that can prevent patients from adhering to treatment recommendations. Interpersonal interventions provide the context in which the behavioral and cognitive interventions are implemented. Case examples illustrate key concepts.

Cognitive Therapy for Auditory Hallucinations: A Theory-Based Approach
Anthony P. Morrison and Julia C. Renton, Mental Health Services of Salford and University of Manchester

Auditory hallucinations, probably the most common symptom of schizophrenia, are usually very distressing for patients. In this paper it is suggested that a combination of the interpretations of voices and the content of voices cause the majority of this distress, and treatment approaches based on this assumption are outlined. Specifically, a cognitive therapy for voices based on recent cognitive conceptualizations of auditory hallucinations is described, involving challenging the interpretations of voices, challenging the content of voices, and modifying focus of attention. These are illustrated with reference to clinical cases.

Metacognitive Beliefs About Rumination in Recurrent Major Depression
Costas Papageorgiou, University of Manchester and North Manchester NHS Trust, and Adrian Wells, University of Manchester

Wells and Matthews (1994, 1996) proposed that perseverative negative thinking, such as depressive rumination and anxious worry, is supported by metacognitive beliefs concerning the functions and consequences of these styles of thinking. However, to date no studies have investigated metacognitive beliefs about rumination. This study examined the presence and content of metacognitive beliefs about rumination in patients with recurrent major depression. To achieve this aim, a semistructured interview was conducted with each patient. The results showed that all patients held positive and negative beliefs about rumination. Positive beliefs appear to reflect themes concerning rumination as a coping strategy. Negative beliefs seem to reflect themes concerning uncontrollability and harm, and interpersonal and social consequences of rumination. The conceptual and clinical implications of the results are discussed.

A Brief Behavioral Activation Treatment for Depression
C. W. Lejuez and Derek R. Hopko, West Virginia University, James P. LePage, West Virginia University School of Medicine, and Sandra D. Hopko and Daniel W. McNeil, West Virginia University

A time-limited behavioral treatment of depression is described, based upon the matching law, targeting both environmental factors maintaining depressive behaviors and factors limiting the occurrence of more healthy behaviors. This treatment is designed to reduce depression by way of a gradual increase in desired, healthy activity. Three case studies using this intervention are provided, with marked improvement evidenced in each case. Although considerably more work is necessary to establish the general effectiveness of this treatment, it appears to be a parsimonious and effective approach that may help to shed light on the active ingredients of the successful treatment of depression.

COGNITIVE BEHAVIORAL CASE CONFERENCE

The Case of Aleisha: A Presentation of Attention-Deficit/Hyperactivity Disorder With Oppositionality, Anxiety, Peer and School Difficulties
Tracy E. Costigan, SPSS Inc., Washington, DC

This paper and the next four constitute the CBT case conference on Aleisha, an 8-year-old female with broad behavioral, emotional, academic, and social difficulties. Her case is typical of a child referred for outpatient assessment in its diagnostic comorbidity and need for multisystemic assessment and treatment. The first paper offers case history, assessment results, treatment plan, and initial treatment progress. The authors of the three papers that follow provide case formulation from differing perspectives (biopsychosocial, behavior-analytic, cognitive-behavioral-systemic) and describe further assessment strategies, treatment goals, and anticipated outcomes. The final paper compares and contrasts these differing perspectives.

Culturally Responsive, Biopsychosocial Intervention for ADHD and Related Problems
Ricardo B. Eiraldi, The Children's Hospital of Philadelphia, and Thomas J. Power, University of Pennsylvania School of Medicine

Aleisha H. presents with difficulty sustaining attention, excessive motor activity, and poor impulse control as well as comorbid peer problems, underachievement, oppositional behavior, and an anxiety disorder. Specific family and school characteristics complicate this case and compromise treatment goals. Aleisha's symptom profile can be conceptualized from neuropsychological, behavioral, sociocognitive, and ecological perspectives. The pervasive nature of her difficulties related to ADHD and comorbid problems requires a multimodal treatment approach. A comprehensive treatment plan that includes interventions that affect the child in the settings where problems are most likely to occur is presented. A treatment approach that includes culturally sensitive school and family interventions, an evaluation of family factors that are related to attitudes toward pharmacological treatment, and a multimethod strategy for assessing outcomes is discussed. Common strategies and tools used in multimodal treatments of ADHD are outlined.

A Behavioral Analytic Approach
Peter J. D'Amico, Long Island Jewish Medical Center
This paper offers a comprehensive conceptualization of an 8-year-old African American female through consistent application of learning principles. Using a behavioral analytic approach, focused hypotheses are explored without losing scope of broad clinical issues: traditional diagnostic formulations, therapeutic relationship factors, the prospect of pharmacotherapy, and family system variables. This approach investigates multiple contingencies believed to shape and maintain maladaptive behaviors. Emphasis is placed on identifying ways to reinforce adaptive behavior across domains of functioning in supporting environments. Hypothesis testing is a key component of behavioral assessment and behavior therapy recommendations. Integrating the case's complexity, this approach offers a dynamic view of the evolving therapeutic contract.

A Cognitive, Behavioral, Systemic Plan for a Complicated Case of a Child
Raymond DiGiuseppe, St. John's University

A case formulation from a cognitive behavioral perspective is provided for a complicated case of a young girl who experiences problems of inattention, oppositional behavior, academic underachievement, and peer rejection. The treatment plan integrates a combination of cognitive, behavioral, and systemic approaches. Systemic interventions help design an environment with a goodness of fit to the child's skills and temperament. Behavioral interventions help the grandparents, parents, and teachers encourage more adaptive behavior. Cognitive interventions help the adults overcome their emotional barriers to implementing the behavioral interventions and help the child cope with environmental stressors that cannot be changed.

Summary: Assessment and Treatment of ADHD and Comorbid Diagnoses
Tracy E. Costigan, SPSS Inc., Washington, DC
This is the final paper in the CBT case conference for Aleisha, an 8-year-old African American female whose family self-referred for assessment and treatment of Aleisha's inattentive, hyperactive-impulsive, and oppositional behavior, as well as anxiety, peer problems and academic underachievement. The paper makes concluding comments about treatment progress, and summarizes similarities and differences among the response papers. Responses to the case presentation were similar in their recognition of several clinical assessment and treatment issues. Most striking in their differences were approaches to addressing family systemic issues (relationships and attitudes), broader systemic issues, and cultural factors.