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					   THE
 MENTAL
 HEALTH
   DESK
REFERENCE
       THE
     MENTAL
     HEALTH
       DESK
    REFERENCE

                                    Edited by

               Elizabeth Reynolds Welfel
                   R. Elliott Ingersoll




                            John Wiley & Sons, Inc.
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           To Fred and Brandon who make it all worthwhile.
        To my wife Jenn for offering her critical thinking skills.
To my students for the great questions I hope these chapters will address.
                  PREFACE




This book is designed to be an accessible and             practical guidance to practitioners in serving
authoritative resource for mental health pro-             their clients. The brief chapters are written by
fessionals seeking to provide effective, respon-          many of the best scholars in the field, are in-
sible, and up-to-date services to their clients.          formed by current research, and are presented
In the current economic, political, and social            in a straightforward and practical format that
climate, mental health professionals from                 busy practitioners can readily access.
every discipline struggle to provide competent               The book is unique in several ways. First, it
and caring services to their clients, but feel            combines in a single source both recommenda-
hindered in that endeavor by the limits im-               tions for effective practice and guidance for
posed by third-party payors, the shrinkage in             ethical community practice. Second, it ad-
governmental funding for their work, and the              dresses issues related to multicultural coun-
lack of public understanding or support for               seling and psychotherapy in a concise but
their work. At the same time, they are being              rigorous way. Third, it is inclusive of all men-
held to a higher standard of accountability to            tal health professions that serve clients in the
demonstrate that their services are effective,            community and is not limited to one type of
efficient, and in keeping with the best prac-             practitioner. Its authors, chosen for their ex-
tices identified by research. They are at more            pertise and not their professional identifica-
risk than ever for malpractice claims and                 tion, span virtually all the mental health
ethics complaints against them but also feel so           professions including (in alphabetical order)
overwhelmed by the bureaucracy of serving                 clinical psychology, counseling psychology,
clients with managed care insurance that they             counselor education, psychiatry, and social
often are not able to be as diligent as they want         work. Fourth, this book addresses mental
to be. When they turn to the professional liter-          health service across the life span and across a
ature to guide them, all too often they find              diversity of settings, with the major focus al-
complex and lengthy research papers that                  ways on recommendations for effective and re-
seem too removed from day-to-day practice to              sponsible services to clients in those settings.
be helpful, or simplistic theories and models of             Because the authors come from a variety of
service that have so flimsy a scientific basis            disciplines, they do not use identical termi-
that they cannot feel confident in their use.             nology to refer either to mental health profes-
This book provides a concise resource that                sionals or to the people whom they serve.
gives up-to-date, scientifically sound, and               Some use the terms clinician or therapist and

                                                    vii
viii    PREFACE

patient, others use counselor and client. As        of a team of people, the most important of
editors, we have decided to honor the termi-        whom are the chapter authors. These authors
nology the authors chose and not impose a           succeeded in a daunting task—producing a
conformity. We believe that allowing them to        concise, accurate, and up-to-date discussion of
speak “in their own voices” has resulted in a       the issues in the field in a very confined for-
better book. At the very least, it mirrors more     mat—and the ultimate value of this book lies
closely the multidisciplinary nature of mental      primarily in their hands, although we as edi-
health practice in the community. It also re-       tors take all responsibility for any errors
flects our philosophy that the provision of         found herein. We also wish to thank our col-
competent and caring service to clients takes       leagues at Cleveland State who supported us
precedence over disciplinary differences.           (and took on extra work at times to help us
   The book is divided into nine major parts.       complete this project on schedule) and our
The first 58 chapters focus on effective practice   graduate assistants, Ann O’Neill and Laura
with sections on assessing and treating adult       Burns, who diligently attended to all the work
and child disorders; good practice with adjust-     we gave them. We also wish to thank our edi-
ment issues and normal developmental con-           tor at Wiley, Tracey Belmont, who expertly as-
cerns; crisis intervention; competent service       sisted us at every stage of the process and
with diverse populations and group and fam-         Publications Development Company of Texas.
ily treatment; and practice management. The         Finally, we owe a debt to our families who sup-
second major portion of the book—Chapters 59        ported us in every possible way to complete
through 72—explores the ethical and legal di-       this project.
mensions of practice with attention both to
standards for practice and recommendations                          ELIZABETH REYNOLDS WELFEL
for acting responsibly with emerging technol-                       R. ELLIOTT INGERSOLL
ogy and third-party payors. The book ends                           Cleveland, Ohio
with an appendix containing codes of ethics
and guidelines for readers to access as needed.



ACKNOWLEDGMENTS


A task as comprehensive in scope as this book
could only be completed with the commitment
                 CONTENTS




   Editors xiii                                           8 The Fat Client       51
   Contributors     xv                                           JANET MELCHER AND
                                                                 GERALD J. BOSTWICK JR.

   PART I: COUNSELING FOR ADJUSTMENT
   DISORDERS AND LIFE STRESS                              9 Guidelines for Counseling Clients with
                                                            HIV Spectrum Disorders 60
                                                                 PAU L A J . B R I T T O N
1 Prevalence of Adult Disorders          3
       R. ELLIOTT I NGER SOLL AND
       L AU R A B U R N S
                                                            PART II: DIAGNOSIS AND TREATMENT OF
                                                            ADULTS WITH MENTAL AND
2 Counseling Clients with Underlying
                                                            EMOTIONAL DISORDERS
  Medical Problems 10
       CHR I STIANE BREMS
                                                         10 Effective Use of the DSM from a
                                                            Developmental/Wellness
3 Counseling with Unemployed and
                                                            Perspective 69
  Underemployed Clients 18
                                                                 EARL J. GI NTER AND
       ELLEN B. LEN T
                                                                 A N N G L AU S E R

4 Effective College Counseling          25
       NEAL E. LIPSITZ
                                                         11 Clinical and Diagnostic
                                                            Interviewing 77
                                                                 T I MOT H Y M. L ANE AN D
5 Divorce Counseling         32
                                                                 D ONNA L. FLEM I NG
       K AT H E R I N E M . K I T Z M A N N A N D
       N O N I K . G AY L O R D
                                                         12 Effective Treatment Planning                83
6 Death and Bereavement           38                             C H R I S T O P H E R M . FA I V E R

       STEPHEN J. FREEMAN
                                                         13 The Nonmedical Therapist’s Role
7 Stress, Coping, and Well-Being:                           in Pharmacological Interventions
  Applications of Theory to Practice           44           with Adults 88
       JOHN L. ROMANO                                            R. ELLIOTT I NGER SOLL


                                                    ix
x    CONTENTS

14 Guidelines for Counseling Mandated                 24 Child Maltreatment: Treatment of Child
   and Nonvoluntary Clients 94                           and Adolescent Victims 169
        RONALD H. RO ONEY                                     C I N DY L . M I L L E R - PE R R I N


15 Using Test Data in Counseling and                  25 Treating Anxiety Disorders
   Clinical Practice 99                                  in Children 177
        K AT H R Y N C . M A C C L U S K I E                  CH R I S T OPH E R A. K EAR NEY A N D
                                                              LI SA M. LI NN I NG

16 Treating Anxiety Disorders
   in Adults 106                                      26 Interventions for Attention-Deficit/
        PAU L F. G R A N E L L O A N D                   Hyperactivity Disorder 183
        DA R C Y H A AG G R A N E L L O                       JOEL T. N IG G A N D
                                                              M A R S H A D. R A P P L E Y
17 Diagnosis and Treatment of Adult
   Depressive Disorders 112                           27 Bullying: Counseling Perpetrators
        G A RY G . G I N T N E R                         and Victims 191
                                                              R ICHARD J. HAZLER
18 Eating Disorders: Guidelines
   for Assessment, Treatment,                         28 Assessment and Treatment
   and Referral 119                                      Recommendations for Children and
        CYN T H IA R. KALODNER AN D
                                                         Adolescents with Depression 199
        J E F F R E Y S . VA N L O N E
                                                              BENEDIC T T. MCWH I RT E R A N D
                                                              JAS ON J. BUR ROW
19 Clinical Practice Issues in Assessing for
   Adult Substance Use Disorders 128                  29 Counseling Interventions for Children
        B O Y D W. P I D C O C K A N D
                                                         with Disruptive Behaviors 205
        J OA N P O L A N S K Y
                                                              J O H N S O M M E R S - F L A NAG A N,
                                                              R I TA S O M M E R S - F L A N A G A N , A N D
20 Management of Personality                                  C H A R L E S PA L M E R
   Disorders 135
        DA R C Y H A AG G R A N E L L O A N D
                                                      30 Effective Use of DSM-IV
        PAU L F. G R A N E L L O
                                                         with Children 213
                                                              A LV I N E . H O U S E
21 Schizophrenia and Severe Mental Illness:
   Guidelines for Assessment, Treatment,
                                                      31 Enlisting Appropriate Parental
   and Referral 142
        SUSA N BICHSEL
                                                         Cooperation and Involvement
                                                         in Children’s Mental Health
                                                         Treatment 219
    PART III: DIAGNOSIS AND TREATMENT                         L I N D A TAY L O R A N D
    OF CHILDREN WITH MENTAL AND                               H O WA R D S . A D E L M A N
    EMOTIONAL DISORDERS

                                                      32 Understanding and Promoting Resilience
22 Prevalence of Childhood Disorders            155
        R. ELLIOTT I NGER SOLL AND
                                                         with Our Clients 225
                                                              C A R L F. R A K
        SUSA N B. PR E V I T S


23 Diagnostic Evaluation of Mental and                33 Substance Abuse among Children
   Emotional Disorders of Childhood 162                  and Adolescents 231
        T H O M A S P. S WA L E S                             MICHAEL WI NDLE
                                                                                            CONTENTS          xi

   PART IV: CRISIS INTERVENTION ISSUES                   44 Counseling American Indian/Alaskan
                                                            Native Clients 306
34 Responding to a Community Crisis:                             J O H N J O S E P H PE R E G OY
   Frontline Counseling 239
       A N N B AU E R                                    45 Disability and Rehabilitation
                                                            Counseling 314
                                                                 E . D AV I S M A R T I N J R . A N D
35 Treatment for Violent Children
                                                                 G E R A L D L . G A N DY
   and Adolescents 245
       T O N Y D. C R E S P I
                                                         46 Counseling Older Adults             320
                                                                 VA L E R I E L . S C H W I E B E R T A N D
36 Responding to Survivors of                                    JANE E. M YER S
   Sexual Assault 252
       PAT R I C I A F R A Z I E R ,                     47 Counseling Older Adults in
       J A S O N S T E WA R D ,                             Institutional Settings 326
       T Y TA S H I R O , A N D                                  NA NCY A. OR EL
       SUSA N RO SENBE RGE R
                                                         48 Affirmative Assessment and Therapy with
37 Suicide Risk Assessment             259                  Lesbian, Gay, and Bisexual Clients 333
       JAME S R. RO GER S                                        T H O M A S V. PA L M A


                                                         49 Counseling Women from a
38 Counseling Interventions with
                                                            Feminist Perspective 341
   Suicidal Clients 264
                                                                 PA M R E M E R ,
       R I TA S O M M E R S - F L A N A G A N ,
                                                                 S H A R O N R O S T O S K Y, A N D
       J O H N S O M M E R S - F L A NAG A N, A N D
                                                                 M A R G A R E T L AU R I E C O M E R
       K AT Y L . LY N C H
                                                                    WR IGHT


39 Responding to Dangerous Clients                 271
       DE R E K T RU S C O T T A N D                         PART VI: GROUP AND FAMILY
       J I M E VA N S                                        INTERVENTIONS


                                                         50 Using Brief Groups Effectively              351
   PART V: COUNSELING DIVERSE                                    D AV I D M I C H A E L C O E
   POPULATIONS
                                                         51 Exploring Diversity in
40 Multicultural Assessment             279                 Therapeutic Groups 358
       LI SA A. SUZUK I A N D                                    ROBERT K. CONYNE,
       J O H N F. K U G L E R                                    M E I TA N G , A N D
                                                                 A L B E R T L . WAT S O N
41 Counseling African American
   Clients 286                                           52 Solution-Focused Family
       LOR I R. W ICKER,                                    Counseling 365
       ROBERT E. BRODI E I I, AN D                               CY N T H I A J. O SB OR N,
       D O N A L D R . AT K I N S O N                            J O H N D. W E S T, A N D
                                                                 M E G A N L . PE T RU Z Z I
42 Counseling Asian American
   Clients 292                                           53 Assessment in Couple and
       D AV I D S U E
                                                            Family Counseling 372
                                                                 M I C H A E L J . S P O R A KOW S K I ,
43 Counseling Latino Clients            298                      A N N E M . P R O U T Y, A N D
       R O S E M . Q U I N O N E S D E LVA L L E                 CH R I S T OPH E R H ABBEN
xii     CONTENTS

54 Family Counseling Competencies                379   64 Protecting Clients’ Rights
         M E L A N I E A . WA R N K E                     to Privacy 447
                                                               ELI ZABE T H R EYNOLDS W ELF EL

      PART VII: PRACTICE MANAGEMENT
                                                       65 Accurate and Effective
                                                          Informed Consent 453
55 Practicing Evidence-Based Mental
                                                               M I T C H E L L M . H A N DE L S M A N
   Health: Using Research and
   Measuring Outcomes 387
                                                       66 Responsible Documentation              459
         T HOMAS L. SEXTON AN D
                                                               K AT H R Y N C . M A C C L U S K I E
         MON IQUE C. LI DDLE

                                                       67 Managing Boundaries              465
56 Advertising, Marketing, and Financing a
                                                               BA R BA R A H E R L I H Y
   Mental Health Practice 393
         H O WA R D B . S M I T H
                                                       68 Reporting Suspected Child Abuse               471
                                                               SE T H C. KALICHMAN
57 Counselors Dealing with
   the Media 398
                                                       69 Defining and Recognizing
         J U DI T H A . DE T RU DE
                                                          Elder Abuse 478
                                                               PAU L A R . D A N Z I N G E R
58 Counselors as Expert Witnesses               404
         L A R RY S . S T O K E S A N D
                                                       70 The Responsible Use of Technology in
         T H E O D O R E P. R E M L E Y J R .
                                                          Mental Health Practice 484
                                                               ELI ZABE T H R EYNOLDS W ELF EL
      PART VIII: PERSONAL CARE AND                             A N D K AT H L E E N T . H E I N L E N
      INTERPROFESSIONAL RELATIONS:
      COPING WITH THE DEMANDS OF                       71 Counseling Supervision: Essential
      THE PROFESSION
                                                          Concepts and Practices 490
                                                               RO D N E Y K . G O O DY E A R ,
59 Impairment in the Mental                                    F E RDI NA N D ARCI N UE , A N D
   Health Professions 413                                      MICHELE GETZELMAN
         H O L LY A . S TA D L E R

                                                       72 Responsible Interactions with Managed
60 Ethical Issues Related to                              Care Organizations 496
   Interprofessional Communication               419           ELI ZABE T H R EYNOLDS W ELF EL
         H AR R I E T L. GLO S OF F

                                                       Appendix: Ethics Codes and Guidelines in
61 When Therapists Face Stress and Crisis:             Mental Health Disciplines 503
   Self-Initiated Coping Strategies 426
         J E F F R E Y A . KO T T L E R A N D              Author Index      505
         MARG OT S CHOF I ELD
                                                           Subject Index      521

62 Treatment Failures: Opportunities
   for Learning 432
         L AU R A J . V E A C H



      PART IX: ETHICAL AND LEGAL ISSUES


63 Ethics Complaints: Procedures for Filing
   and Responding 441
         C A R M E N B R AU N W I L L I A M S
                  EDITORS




Elizabeth Reynolds Welfel is Professor and                 R. Elliott Ingersoll is an Associate Profes-
Coordinator of Counselor Education at Cleve-               sor and Chairperson of the Department
land State University. She earned a doctorate in           of Counseling, Administration, Supervision,
counseling psychology at the University of                 and Adult Learning at Cleveland State Uni-
Minnesota in 1979 and is licensed as a psychol-            versity. He is licensed as a Professional Clin-
ogist in Ohio. Prior to her position at Cleveland          ical Counselor and a psychologist in the state
State, she was on the faculty of the counseling            of Ohio. He earned his PhD in counselor ed-
psychology program at Boston College. Dr.                  ucation at Kent State University in 1995. He
Welfel is author of two books, The Counseling
                                                           is the coauthor of two books, Explorations in
Process and Ethics in Counseling and Psychother-
                                                           Counseling and Spirituality and Becoming a
apy, and numerous articles in the professional
                                                           21st Century Agency Counselor as well as nu-
literature. Dr. Welfel’s major research and
                                                           merous articles. His research activities are
teaching activities have centered on promoting
                                                           focused on psychopharmacology and the in-
responsible mental health practices. Her most
                                                           terface between counseling and spirituality.
recent research explores the ethics of Internet
counseling and psychotherapy.




                                                    xiii
                 CONTRIBUTORS




Howard S. Adelman                                Robert E. Brodie II
Department of Psychology                         Graduate School of Education
University of California at Los Angeles          University of California, Santa Barbara

Ferdinand Arcinue                                Laura Burns
Division of Counseling Psychology                PhD Program in Urban Education
University of Southern California                Cleveland State University

Donald R. Atkinson                               Jason J. Burrow
Graduate School of Education                     Counseling Psychology Program
University of California at Santa Barbara        University of Oregon

Ann Bauer                                        David Michael Coe
Department of Psychology and Counseling          Portage Path Behavioral Health Center
Arkansas State University                        Akron, OH

Susan Bichsel                                    Robert K. Conyne
Jewish Family Services Association of            Department of Counseling
   Cleveland                                     University of Cincinnati
Beachwood, OH
                                                 Tony D. Crespi
Gerald J. Bostwick Jr.                           Department of Psychology
School of Social Work                            University of Hartford
University of Cincinnati
                                                 Paula R. Danzinger
Christiane Brems                                 Department of Special Education and
Department of Psychology                           Counseling
University of Alaska                             William Paterson University

Paula J. Britton                                 Judith A. DeTrude
Department of Counseling and Human               Department of Educational Leadership
   Services                                         and Counseling
John Carroll University                          Sam Houston State University

                                            xv
xvi    CONTRIBUTORS

Jim Evans                                 Paul F. Granello
Department of Psychology                  Counselor Education
University of Alberta                     The Ohio State University
Christopher M. Faiver                     Christopher Habben
Department of Counseling and Human        Department of Human Development
   Services                               Virginia Polytechnic Institute and State
John Carroll University                      University
Donna L. Fleming
                                          Mitchell M. Handelsman
Director of Counseling and Research
                                          Department of Psychology
University of North Texas
                                          University of Colorado at Denver
Patricia Frazier
Department of Psychology                  Richard J. Hazler
University of Minnesota                   Department of Counselor Education
                                          Ohio University
Stephen J. Freeman
Department of Family Sciences             Kathleen T. Heinlen
Texas Women’s University                  PhD Program in Urban Education
Gerald L. Gandy                           Cleveland State University
Department of Rehabilitation Counseling   Barbara Herlihy
Virginia Commonwealth University          Department of Educational Leadership,
Noni K. Gaylord                              Counseling and Foundations
Department of Psychology                  University of New Orleans
University of Memphis                     Alvin E. House
Michele Getzelman                         Department of Psychology
Division of Counseling Psychology         Illinois State University
University of Southern California
                                          R. Elliott Ingersoll
Earl J. Ginter                            Counseling, Administration, Supervision,
Counseling and Human Development             and Adult Learning
   Services                               Cleveland State University
University of Georgia
                                          Seth C. Kalichman
Gary G. Gintner                           Department of Psychiatry and Behavioral
Department of Educational Leadership,        Medicine
  Research and Counseling
                                          Medical College of Wisconsin
Louisiana State University
                                          Cynthia R. Kalodner
Ann Glauser
                                          College of Human Resources and Education,
Counseling and Human Development
                                            Counseling
  Services
                                          West Virginia University
University of Georgia
Harriet L. Glosoff                        Christopher A. Kearney
Department of Counselor Education         Department of Psychology
University of Virginia                    University of Nevada, Las Vegas

Rodney K. Goodyear                        Katherine M. Kitzmann
Division of Counseling Psychology         Department of Psychology
University of Southern California         University of Memphis
Darcy Haag Granello                       Jeffrey A. Kottler
Counselor Education                       Department of Counseling
The Ohio State University                 California State University, Fullerton
                                                                  CONTRIBUTORS          xvii

John F. Kugler                               Joel T. Nigg
Bay Ridge Preparatory School                 Department of Psychology
Brooklyn, NY                                 Michigan State University

Timothy M. Lane                              Nancy A. Orel
Counseling and Testing Services              Gerontology Program
University of North Texas                    Bowling Green State University

Ellen B. Lent                                Cynthia J. Osborn
Department of Counseling and Personnel       Counseling and Human Development
                                               Services
   Services
                                             Kent State University
University of Maryland, College Park
                                             Thomas V. Palma
Monique C. Liddle
                                             Counseling, Administration, Supervision,
Department of Counseling and Educational
                                                and Adult Learning
   Psychology
                                             Cleveland State University
Indiana University
                                             Charles Palmer
Lisa M. Linning                              Counselor Education Program
Department of Psychology                     University of Montana
University of Nevada at Las Vegas
                                             John Joseph Peregoy
Neal E. Lipsitz                              Department of Educational Psychology
Director of Counseling Services              University of Utah
Holy Cross College
                                             Megan L. Petruzzi
Katy L. Lynch                                Counseling and Human Development
Department of Psychology                       Services
University of Montana                        Kent State University

Kathryn C. MacCluskie                        Boyd W. Pidcock
Counseling, Administration, Supervision,     Department of Counseling Psychology
   and Adult Learning                        Lewis and Clark College
Cleveland State University                   Joan Polansky
E. Davis Martin Jr.                          Northern Arizona University
Department of Rehabilitation Counseling      Statewide Programs
Virginia Commonwealth University             Susan B. Previts
                                             Counseling and Human Development
Benedict T. McWhirter
                                               Services Program
Counseling Psychology Program
                                             Kent State University
University of Oregon
                                             Anne M. Prouty
Janet Melcher
                                             Family Therapy Center
School of Social Work
                                             Virginia Polytechnic Institute and State
University of Cincinnati                        University
Cindy L. Miller-Perrin                       Rose M. QuinonesDelValle
Social Sciences Division                     Counseling, Administration, Supervision,
Pepperdine University                           and Adult Learning
Jane E. Myers                                Cleveland State University
Department of Counseling and Educational     Carl F. Rak
   Development                               Director, PhD Program in Urban Education
University of North Carolina at Greensboro   Cleveland State University
xviii   CONTRIBUTORS

Marsha D. Rappley                          Michael J. Sporakowski
Department of Pediatrics                   Department of Human Development
Michigan State University                  Virginia Polytechnic Institute and State
Pam Remer                                     University
Department of Psychology                   Holly A. Stadler
University of Kentucky                     Counseling and Counseling Psychology
Theodore P. Remley Jr.                     Auburn University
Department of Counseling, Educational
                                           Jason Steward
  Leadership and Foundations
                                           Department of Psychology
University of New Orleans
                                           University of Minnesota
James R. Rogers
Department of Counseling and Special       Larry S. Stokes
   Education                               Private Practice
The University of Akron                    Metairie, LA
John L. Romano                             David Sue
Department of Educational Psychology       Department of Psychology
University of Minnesota                    Western Washington University
Ronald H. Rooney                           Lisa A. Suzuki
Department of Social Work
                                           Department of Applied Psychology
University of Minnesota
                                           New York University
Susan Rosenberger
                                           Thomas P. Swales
Department of Psychology
University of Minnesota                    Director, Psychological Assessment Center
                                           MetroHealth Medical Center
Sharon Rostosky
                                           Cleveland, OH
Department of Psychology
University of Kentucky                     Mei Tang
                                           Department of Counseling
Valerie L. Schwiebert
Department of Counselor Education          University of Cincinnati
Western Carolina University                Ty Tashiro
Margot Schofield                           Department of Psychology
University of New England                  University of Minnesota
Armidale, Australia
                                           Linda Taylor
Thomas L. Sexton                           Los Angeles Public Schools and
Department of Counseling and Educational   University of California at Los Angeles
   Psychology
Indiana University                         Derek Truscott
                                           Department of Psychology
Howard B. Smith
                                           University of Alberta
American Counseling Association
Alexandria, VA                             Jeffrey S. Van Lone
John Sommers-Flanagan                      College of Human Resources and Education,
Families First                                 Counseling
Missoula, MT                               West Virginia University

Rita Sommers-Flanagan                      Laura J. Veach
Counselor Education Program                Counselor Education Program
University of Montana                      Wake Forest University
                                                                 CONTRIBUTORS          xix

Melanie A. Warnke                          Lori R. Wicker
Counseling and Human Development           Graduate School of Education
  Services Program                         University of California at Santa Barbara
Kent State University
                                           Carmen Braun Williams
Albert L.Watson                            Division of Counseling Psychology and
Department of Counseling                     Counselor Education
University of Cincinnati                   University of Colorado at Denver
Elizabeth Reynolds Welfel                  Michael Windle
Counseling, Administration, Supervision,   Department of Psychology
   and Adult Learning                      University of Alabama
Cleveland State University
                                           Margaret Laurie Comer Wright
John D. West                               Department of Psychology
Counseling and Human Development           University of Kentucky
   Services Program
Kent State University
                  1 • WELFEL UNPAGED GALLEYS   1




PART I
Counseling for Adjustment
Disorders and Life Stress
                 PREVALENCE OF
       1         ADULT DISORDERS


                 R. Elliott Ingersoll and Laura Burns




The notion of prevalence occurs in medical            prevalence estimates found in the various Di-
and psychological research but the methods            agnostic and Statistical Manuals. Epidemio-
used to estimate prevalence yield far more            logic research may be carried out by one or
general results than many clinicians may              two persons or in massive projects like the
suppose. Prevalence is determined through             NIMH Epidemiologic Catchment Area Pro-
statistical probability and, as the mathemati-        gram (Eaton & Kessler, 1985).
cian Morris Kline (1972) noted, statistics are           DuPont, DuPont, and Spencer (1999) stated
first and foremost a confession of ignorance.         that the epidemiology of mental/emotional
The statistics with which mental health pro-          disorders was really begun in the 1970s in the
fessionals estimate the prevalence of men-            Epidemiologic Catchment Area (ECA) study
tal/emotional disorders are drawn from                that used large samples from five communi-
epidemiological research. Epidemiological             ties in the United States. From this data, gen-
research is the study of the incidence, distri-       eralizations were extrapolated to the U.S.
bution, and consequences of particular prob-          population in general producing the first na-
lems in one or more specified populations as          tional estimates for specific disorders. They
well as factors that affect distribution of the       noted that the first “truly national sample”
problems in question (Barlow & Durand,                was the National Comorbidity Study (NCS)
1999; U.S. Department of Health, Education,           conducted between 1990 and 1992 that used
and Welfare, 1978).                                   DSM-III-R criteria.
   Gathering accurate statistics on mental               Since statistics are first and foremost a
and emotional disorders has always been a             confession of ignorance, prevalence data
challenging task. The Association of Medical          based on statistics are always works in prog-
Superintendents of American Institutions for          ress to be understood as “best guesses” given
the Insane (later renamed the American Psy-           available methodologies. Several problems
chiatric Association—APA) first initiated this        challenge researchers to make accurate esti-
task in 1917. The responsibility for gathering        mates regarding the prevalence of a particular
statistics was shifted to the Biometrics branch       disorder. First, there is a significant time lag
of the National Institute of Mental Health            between the refinement of an edition of the
(NIMH) in 1949 (American Psychiatric Asso-            DSM, and the gathering and analysis of data.
ciation, 2000a). The APA relies heavily on the        For example, studies are still being published
epidemiological research of others for the            estimating prevalence based on DSM-III-R

                                                  3
4    PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

criteria (Kessler et al., 1997) that was replaced   chiatry have been and will continue to be ten-
in 1994 by DSM-IV (which was replaced in 2000       tative as long as disorders are grouped on the
by DSM-IV-TR). When the DSM is updated, ad-         basis of signs and symptoms elicited in inter-
ditional disorders may be added and criteria or     views” (pp. 146 –147).
descriptors associated with a disorder may             Perhaps the most substantial problem with
change. For example the DSM-IV (APA, 1994)          epidemiological data is summarized by Blazer
added Bipolar II Disorder to describe individu-     and Kaplar (2000) who stated that a central
als who suffered from major depressive epi-         conflict is whether or not symptoms reported
sodes and a low-grade mania (hypomania) but         by community residents in structured inter-
not mania proper. DSM-IV-TR (APA, 2000b)            views are clinically significant or not. On one
went on to make changes in the narrative sec-       side of the debate, Regier (2000) noted that
tion describing the relationship between Bipo-      the conflict could be resolved with better re-
lar I Disorder and Bipolar II disorder.             search methods that would allow a diagnosis
   A second problem associated with estimat-        to be made from the results of a structured
ing prevalence has to do with the methods           clinical interview. On the other side, Spitzer
used. As any researcher knows, some re-             (1998) and Frances (1998) have asserted that
search methods are better than others. There        data from epidemiological studies cannot re-
is a paucity of research comparing various          place clinical judgment. Blazer and Kaplar
methods or data gathering instruments               (2000) contended that the conflict could not be
(Boyle et al., 1997; Regier, 2000) and reported     resolved because the methodologies of both
prevalence rates may vary study by study            sides are plagued with measurement error.
(Regier et al., 1998). Methods of epidemiolog-         In this chapter, we briefly review the
ical research on mental disorders have varied       prevalence of the most common adult disor-
over time. Kohn, Dohrenwend, and Mirotznik          ders. We have organized the chapter so the
(1998) stated that there have been three            disorders are presented in the same order as
generations of evolving, large-scale epidemio-      they appear in the DSM. Disorders usually
logical research using two strategies. Each         first diagnosed in infancy, childhood, or ado-
generation has used different psychiatric           lescence can be found in Chapter 20. Mental
nosologies and data collection tools. The first     disorders due to or related to general medical
generation relied primarily on institutional        conditions are omitted as are many subtypes
records and key informants but no real stan-        of larger syndromes (e.g., dementia due to
dardized procedures for data collection. The        head trauma). There are numerous disorders
second generation utilized structured inter-        for which there are no clear epidemiological
views in the community by nonclinical inter-        data (e.g., Pain Disorder, Factitious Disorder,
viewers that were subsequently rated by a           and all of the Dissociative Disorders). These
psychiatrist. The third generation (starting        have also been omitted from this chapter.
around 1980) used clinician and trained non-           Some disorders are discussed in terms of
clinician interviewers in the community to          point prevalence, some in terms of lifetime
obtain information necessary to determine           prevalence, and some in terms of both. Point
the presence of mental disorders as catego-         prevalence refers to the estimated proportion
rized in the DSM. This present generation uti-      of people in the population thought to suffer
lizes explicit diagnostic criteria as well as       from the disorder at any given time. Lifetime
structured clinical interview schedules             prevalence is an estimate at a given time of all
(Dohrenwend, 1998; Eaton & Kessler, 1985;           individuals who have ever suffered from the
Kohn et al., 1998). Currently, all epidemio-        disorder. Incidence refers to the rate of new
logic approaches are based on personal inter-       cases in a specified period of time (usually an-
views and there is still controversy over           nually) (LaBruzza, 1997). Which of these types
the accuracy of the interview method particu-       of prevalence or incidence data should be cited
larly over whether it is appropriate to use         depends on the availability of data. Unless oth-
lay-interviewers (Dohrenwend, 1998). Dohen-         erwise noted, estimates of prevalence are
wend noted “. . . classification systems in psy-    taken from DSM-IV-TR (APA, 2000b).
                                                   1 • PREVALENCE OF ADULT DISORDERS               5

Attention Deficit Hyperactivity Disorder (ADHD).   unable to function without it. Data on physi-
Although there is limited prevalence data on       cal dependence varies depending on the sub-
ADHD in adults, it is estimated that of the 3%     stance. It should be noted that although each
to 9% of children suffering from the disorder,     subcategory below bears the generic label for
the disorder will persist into adulthood for       disorders related to a substance (e.g., Alcohol-
10% to 50% of these afflicted children (Levin      Related Disorders), for most subcategories,
& Donaldson, 1999). Barkely (1998) has noted       all we have are estimates of use which give us
that the DSM criteria sets are developmentally     no clue as to how many users would meet the
insensitive so he believes that the percentages    criteria for abuse or dependence.
of afflicted children who will continue to suf-    Alcohol Dependence (AD). Estimates of preva-
fer from the disorder in adulthood range from      lence vary markedly across studies for both al-
3% to 68%. Barkley’s point is that patients may    cohol abuse and dependence. Using DSM-III-R
outgrow the diagnosis but not the disorder.        and DSM-IV criteria, it is estimated that
Delirium. The point prevalence is estimated at     the lifetime risk for alcohol dependence in the
0.4% in adults 18-years-old and older. The         mid-1990s was approximately 15% with the
point prevalence for adults 55 and older is es-    point prevalence being 5%. According to
timated at 1.1%. In hospitalized patients with     the ECA survey, 37% of people with an alcohol
medical illness, the point prevalence ranges       disorder had another comorbid mental/emo-
from 10% to 30% and up to 60% of nursing           tional disorder (Gallant, 1994).
home residents age 75 and older may be deliri-     Amphetamine-Induced Disorders. The DSM-IV-
ous at any given time.                             TR notes that the patterns of amphetamine use
Dementia. Dementia may have one of 75 or           differ geographically and over time in the gen-
more etiologies. 1% to 5% of these are re-         eral population. More recent estimates report
versible while approximately 95% are pro-          approximately 5% of adults ever using stimu-
gressive (Alzheimer’s type being the most          lant drugs to get “high” with 1% reporting
common progressive dementia) (Nussbaum,            such activities in the prior year. A national
1998). Prevalence figures vary study by study      epidemiological study in the early 1990s re-
and range from 1.4% to 1.6% for individuals        ported a lifetime prevalence of 1.5%. Although
between the ages of 65 to 69. The prevalence       these estimates are thought to address am-
increases with age and rises to 16% to 25% for     phetamines proper and amphetamine-like sub-
individuals over 85 years of age.                  stances, they probably do not address the
Dementia of the Alzheimer’s Type (ALZ). Like       full chemical diversity of the amphetamine
progressive dementias in general, ALZ inci-        molecule and the chemical variations that are
dence increases with the age of the cohort         produced and sold illegally. For example,
under study. At age 65, the prevalence is 0.6%     3,4-methylenedioxymethamphetamine (“Ec-
in males and 0.8% in females. Respectively,        stasy”) is technically an amphetamine deriva-
these increase to 11% and 14% at age 85 and        tive but is classed as a hallucinogen.
21% and 25% at age 90.                             Caffeine-Related Disorders. It is estimated that
Substance Use Disorders (SUDs). It is difficult    80% to 85% of adults consume caffeine within
to make estimates of substance use disorders       any given year and larger numbers of youth
with adults particularly when the use of nu-       are thought to be using caffeine products. The
merous licit and illicit substances may be         prevalence of caffeine-related disorders is un-
common and even culturally reinforced. In          known.
addition, the very notion of substance abuse       Cannabis-Related Disorders. Marijuana is esti-
as a syndrome meriting inclusion in DSM is         mated to be the most frequently abused il-
still debated (Helzer, 1994). Mirin et al.         licit psychoactive drug in the United States.
(2000) estimated that approximately 15% of         Because of the legal issues involved and the
regular users of any substance will become         variable patterns of use, it is difficult to esti-
psychologically dependent on that sub-             mate the number of users meeting the crite-
stance, that is, they come to believe they are     ria for abuse or dependence. A 1992 survey
6     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

estimated that lifetime rates of cannabis de-        Hispanics. Increases in smoking have been re-
pendence or use are approximately 5%. Use            ported since the mid-1990s for women with
has been estimated for adults 18 to 29 who           less than a high school education. It is esti-
ever used (26%), to used in the last 30 days for     mated that 17% of Americans have ever used
high school seniors (14%), to daily use in high      smokeless tobacco products but there are no
school seniors and young adults (3.7% of adult       estimates for dependence in this group.
males and 1.6% of adult females (Millman &           Opioid-Related Disorders. In 1996, 4% of men
Beeder, 1994).                                       and 6% of women were estimated to have ever
Cocaine-Related Disorders. The patterns of co-       used an analgesic drug in a manner other than
caine use are believed to fluctuate with the         that for which it was prescribed (2% in the past
times. A 1996 national survey estimated that         year). The 18- to 25-year-old cohort had the
10% of the population had ever used cocaine          highest prevalence of ever using an analgesic
and 2% had used it in the previous year.             in this manner (9%). The lifetime prevalence
Crack use was less prevalent with 2% of the          for heroin use is around 1%.
population estimated to have ever used and           Phencyclidine-Related Disorders. Data from 1996
0.6% using in the last year.                         reported that 3% of Americans ages 12 and
Hallucinogen-Related Disorders. The estimation       older have ever used phencyclidine (PCP) with
of hallucinogen-related disorders is compli-         the highest lifetime prevalence (4%) being re-
cated by the disagreement over which sub-            ported in the 26 to 34 year old age group. Phen-
stances are hallucinogens proper. The current        cyclidine is thought to account for about 3% of
category includes 3,4-methylenedioxymetham-          substance-related deaths.
phetamine which is chemically an ampheta-
                                                     Sedative, Hypnotic, or Anxiolytic-Related Disor-
mine derivative and experientially an
                                                     ders. More than 15% of Americans use these
empathogen rather than a hallucinogen. Until
                                                     medications in any given year. Most take as
current disagreements regarding classification
                                                     directed without any misuse. 1996 data esti-
are resolved, it is unlikely that we will have ac-
                                                     mate that 6% of Americans have ever taken
curate prevalence estimates. According to the
                                                     these drugs illicitly. The age group with the
1996 survey used by the writers of the DSM-IV-
                                                     highest estimated illicit use was 26- to 34-
TR, 10% of the population age 10 and older is
                                                     year-olds (3% using “sedatives” and 6% using
estimated to have ever used a hallucinogen.
                                                     “tranquilizers”).
Inhalent-Related Disorders. It is difficult to es-
                                                     Schizophrenia. Schizophrenia is observed across
timate the prevalence of these because it is
                                                     cultures, worldwide. The prevalence among
thought their use might be underrepresented
                                                     adults is thought to be between 1% and 1.5% of
in surveys. The current estimates from the
                                                     adults.
1996 survey indicate that around 6% of the
U.S. population is thought to have ever used         Delusional Disorder. This disorder is thought to
an inhalant with 1% reporting use in the past        be uncommon in outpatient clinical settings. It
year.                                                is estimated that the disorder is prevalent in
                                                     1% to 2% of inpatient mental health facilities.
Nicotine-Related Disorders. As of the 1996 data,
72% of the U.S. population is thought to have        Major Depressive Disorder (MDD). The lifetime
ever used cigarettes with 32% using in the           prevalence of MDD varies between 10% to
past year. Lifetime prevalence is highest for        25% for females and 5% to 12% for males. The
those 35 and older (78%) but use in the prior        point prevalence varies from 5% to 9% for fe-
year was highest in the 18 to 25 year old age        males and 2% to 3% for males.
group (45%). It is estimated that 80% to 90%         Dysthymic Disorder (DD). Estimates vary re-
of regular smokers have nicotine dependence,         garding DD. Lifetime prevalence is esti-
which equals an estimate of 25% of Ameri-            mated to be 6% while the point prevalence is
cans. Greater decreases in smoking are seen          thought to be around 3%. Keller and Russell
for Caucasians than African Americans or             (1996) have noted that chronic depression is
                                                    1 • PREVALENCE OF ADULT DISORDERS             7

generally common in community samples               criminal violence) yield even broader preva-
with 2.7% to 4.3% being diagnosed with DD.          lence rates ranging from 3% to 58%.
Bipolar I Disorder. The estimated lifetime          Acute Stress Disorder. The prevalence of Acute
prevalence of Bipolar I disorder in community       Stress Disorder in the general population is not
samples fluctuates between 0.4% to 1.6%.            known. However, for victims of severe trauma,
Bipolar II Disorder. There is scant data on Bipo-   it is estimated to be between 14% and 33%.
lar II disorder partially because of its newness    Generalized Anxiety Disorder (GAD). The point
(first listed in DSM-IV) and because of diffi-      prevalence for GAD has been estimated at 2%
culties making the diagnosis accurately. Cur-       for females and 4% for males (Wittchen,
rent estimates of lifetime prevalence are 0.5%      Zhao, Kessler, & Eaton, 1994) Lifetime preva-
of the population.                                  lence is estimated at 5%.
Cyclothymic Disorder. Studies estimate the          Somatization Disorder. Studies have reported
prevalence to be between 0.4% and 1% of the         widely variable prevalence rates ranging from
population. The prevalence in mood disorders        0.2% to 2% for women and less than 0.2%
clinics is higher, between 3% and 5%.               for men.
Panic Disorder (with or without Agoraphobia).       Conversion Disorder. Reported rates for Con-
Most studies report rates between 1% and 2%         version Disorder vary widely and are not well
although some estimate as high as 3.5% of the       defined. They range from 11 people out of
general population. The one-year prevalence         every 100,000 to 500 people in every 100,000.
rates range between 0.5% and 1.5% of the            Hypochondriasis. The incidence of hypochon-
population.                                         driasis is estimated to be 2% to 7% in general
Specific Phobia. Phobias are common in the          medical practice. The prevalence for the gen-
general population although they rarely reach       eral population is estimated at 1% to 5%.
the level of distress or impairment necessary       Sexual Disorders. Scant epidemiological data
to qualify as a mental and emotional disorder.      exists on the sexual disorders. The DSM-IV-TR
Estimated prevalence varies depending on            relies on one comprehensive study that sum-
the threshold used to determine distress and        marizes sexual complaints that may be related
impairment. In community samples preva-             to particular disorders. There is no way of
lence estimates range between 4% and 8.8%.          knowing if the complaints would reach the lev-
Lifetime prevalence estimates range between         els of distress and impairment necessary to ac-
7.2% and 11.3%.                                     tually make the diagnosis.
Social Phobia (SB). The estimated lifetime          Hypoactive Sexual Desire Disorder. The one
prevalence is 3% to 13%. The 6-month preva-         comprehensive study to date has estimated
lence is estimated to be 0.9% to 1.7% for males     that as many as 33% of women may suffer
and 1.5% to 2.6% for females (Myers et al.,         from complaints in this category at any given
1984). In the general population most people        time. Clearly this high number may include
with SB have a fear of public speaking.             complaints related to the context of the per-
Obsessive-Compulsive Disorder (OCD). Lifetime       son’s life that may never qualify as the disor-
prevalence is estimated at 2.5% and 1-year          der proper.
prevalence between 0.5% to 2.1%. The average        Arousal Problems. The problems in this cate-
age of onset ranges from early adolescence to       gory could be prominent in Female Sexual
the mid-twenties.                                   Arousal Disorder and Male Erectile Disorder.
Posttraumatic Stress Disorder (PTSD). The life-     It is estimated that at any given time, 20% of
time prevalence for PTSD ranges from 1% to          females may have complaints related to
14% and the variability is related to the           arousal problems and 10% of males would have
methodology used and the population sam-            complaints related to erectile dysfunction.
pled. Studies of at-risk individuals (e.g., com-    Orgasm-Related Problems. The problems in this
bat veterans, victims of volcanic eruption or       category could be related to Female Orgasmic
8    PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

Disorder, Male Orgasmic Disorder, and Pre-       manual. One problem is great comorbidity
mature Ejaculation. At any given time, 25% of    where 50% of people meeting the criteria for
females and 10% of males are estimated to        one personality disorder also meet the crite-
have complaints related to orgasms.              ria for at least one more. Tyrer (1995) stated
Dyspareunia. Problems that may fit this cate-    that “the degree of overlap between and
gory given sufficient impairment and distress    among the different personality disorders is
are estimated to be experienced by 3% of         far too great, and the specious use of the term
males and 15% of females.                        “comorbidity” hides diagnostic confusion”
                                                 (p. 29). He concluded that even if the cate-
Anorexia Nervosa. Lifetime prevalence among
                                                 gories were more valid, there is no way to
females is estimated to be 0.5% of the popula-
                                                 classify a person meeting the criteria for more
tion although there are many more women
                                                 than one personality disorder. Without going
who are suffering from related symptoms that
                                                 further into the debate about the validity of
are sub-threshold for the disorder. Prevalence
                                                 these categories, suffice it to say that one
in males is thought to be 1⁄10 that of women.
                                                 should be mindful of the debate while reading
Bulimia Nervosa. The general prevalence is es-   current prevalence data. Disorders for which
timated to be 1% to 3% among adolescent and      there is no prevalence data (e.g., Schizoid Per-
young adult females. Male occurrence is          sonality Disorder) have been omitted from
thought to be 1⁄10 of that.                      this chapter.
Primary Insomnia. Primary Insomnia is            Paranoid Personality Disorder. Estimated to be
thought to afflict 1% to 10% of the general      present in between 0.5% and 2.5% of the gen-
population and up to 25% of elderly people.      eral population.
Narcolepsy. Studies estimate that between        Schizotypal Personality Disorder. Estimated to
0.02% and 0.16% of the population is afflicted   be present in 3% of the general population.
with Narcolepsy.
                                                 Antisocial Personality Disorder. Estimated to be
Breathing-Related Sleep Disorders. The most      present in 3% of males and 1% of females in
common of these is Obstructive Sleep Apnea       the general population.
Syndrome which is thought to afflict between
                                                 Borderline Personality Disorder. Estimated to
1% and 10% of the population.
                                                 be present in 2% of the general population.
Sleepwalking Disorder. The prevalence of
                                                 Histrionic Personality Disorder. Limited data
sleepwalking disorder is thought to be in the
                                                 allow for estimates of about 2% to 3% of the
range of 1% to 5% while incidents of sleep-
                                                 general population.
walking (not the disorder per se) are more
common for up to 7% of adults.                   Narcissistic Personality Disorder. Estimated to
                                                 exist in less than 1% of the general population.
Pathological Gambling. This is the only disor-
der in the category of Impulse-Control Disor-    Avoidant Personality Disorder. Estimated to
ders Not Elsewhere Classified with any           exist in between 0.5% and 1% of the general
community estimates. For adults, the esti-       population.
mated prevalence is 0.4% to 3.4%.                Obsessive-Compulsive Personality Disorder. Esti-
Adjustment Disorders (AD). It is estimated       mated to be present in approximately 1% of
that between 10% and 30% of clients in men-      the general population.
tal health outpatient settings suffer from ad-
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                    COUNSELING CLIENTS
        2           WITH UNDERLYING
                    MEDICAL PROBLEMS


                    Christiane Brems




In recent years, studies have documented a                the possibility that clients presenting for one
strong link between medicine and psychology,              reason (e.g., medical concerns or psychological
as many clients with mental health concerns               problems) may also or instead suffer from a
actually suffer from medical illness and vice             condition in the realm of the other provider
versa. Tomb (1995) found that 50% to 80% of               (Wickramasekera et al., 1996). These over-
patients treated in medical clinics actually had          sights could be prevented if both providers
a diagnosable psychiatric disorder; 60% of pa-            were more willing to consider the importance
tients treated by general medical practitioners           of the other and more open to working collabo-
actually needed mental health care; and 50%               ratively (Brems, 2000). Doubtless, such collab-
of patients in psychiatric clinics had undiag-            oration enhances the quality of treatment (and
nosed medical illnesses. Wickramasekera,                  life) of clients who are in need of medical and
Davies, and Davies (1996) showed that over                psychological interventions. Not surprisingly,
half of patient visits to primary care physi-             lawsuits increasingly are brought against psy-
cians were related to psychosocial problems,              chological providers who failed to investigate
although presented to the provider in the form            possible underlying physical diagnoses that
of physical complaints. Klonoff and Landrine              would have explained a client’s psychological
(1997) accumulated evidence that as many as               symptoms (Klonoff & Landrine, 1997). Thus,
41% to 83% of psychiatric patients instead suf-           for the sake of their clients and to minimize
fer from an undiagnosed medical illness.                  their own risk of being sued for malpractice,
   These numbers show that counselors must                counselors need to be knowledgeable about
be aware of clients’ physical needs as much               medical referrals and have collaborative rela-
as medical providers need to consider pa-                 tionships with medical providers. This means
tients’ emotional state. Both medical and                 raising their awareness of physical and psy-
psychological providers often fail to consider            chological symptoms that should stimulate
                    2 • COUNSELING CLIENTS WITH UNDERLYING MEDICAL PROBLEMS                     11

referrals (Samson, Levin, & Richardson, 1998;        tumors,     infection,    complex      partial
White, Marans, & Krengel, 1998).                     seizures, migraines; peptic ulcers and ul-
                                                     cerative colitis).
                                                 •   Major Depression (e.g., malignancies; CNS
PSYCHOLOGICAL SYMPTOMS THAT REQUIRE                  impairment such as uremia, demyelination,
MEDICAL DIFFERENTIAL DIAGNOSIS                       hypoxia, hepatic encephalopathy, infections
                                                     such as hepatitis, mononucleosis, syphilis;
Not making appropriate medical referrals             nutritional deficiencies; endocrine disor-
when psychological symptoms have medical             ders such as hypo- and hyperthyroidism,
causes can lead to lack of problem resolution        diabetes, pituitary insufficiency, Cushing’s
at best and life-threatening situations at           syndrome, Addison’s disease).
worst. Thus, it is crucial that counselors be    •   Mania (e.g., hypo- or hyperthyroidism, di-
aware of possible differential medical diag-         encephalic or frontal stroke, multiple sclero-
noses. Psychological symptoms that should            sis, complex partial seizures, brain tumors).
stimulate data gathering for possible medical    •   Panic Disorder (e.g., cardiovascular dis-
referral follow, with medical causes to be           ease, especially mitral valve prolapse; res-
ruled out in parentheses:                            piratory disease; neurological disease;
                                                     endocrine disorder; pheochromocytoma).
• Anorexia Nervosa (e.g., Crohn’s disease, hy-   •   Psychogenic Amnesia (e.g., organic amnes-
  popituitarism, systemic lupus erythemato-          tic disorder, epilepsy, postconcussion am-
  sus).                                              nesia, substance-induced amnesia).
• Delirium (e.g., drug toxicity or with-         •   Psychogenic Fugue (e.g., organic mental
  drawal, metabolic disease, psychosocial            disorder, complex partial seizures, malin-
  trauma or stress, postoperative and postic-        gering).
  tal states, CNS trauma, infection).            •   Schizophrenia (e.g., epilepsy, partial com-
• Delusional Disorder (e.g., metabolic/              plex seizures, CNS tumor or infection,
  endocrine disorder such as thyroid dis-            CNS degenerative disease, B12 and/or folic
  turbance, CNS lupus, hypopituitarism,              acid deficiency, endocrine/metabolic dis-
  Cushing’s syndrome; neurological disor-            ease, toxicity, multiple sclerosis).
  ders such as temporal lobe epilepsy; Wil-      •   Sexual Dysfunction (e.g., neurophysiologi-
  son’s disease).                                    cal factors, side effect of drug or medica-
• Dementia (e.g., primary dementia such              tion use, general medical illness).
  as Alzheimer’s disease, Pick’s disease,        •   Insomnia (e.g., organic factors such as
  Creutzfeldt-Jakob disease; endocrine dis-          Parkinson’s disease; cardiovascular insuf-
  order; infections, including HIV; tumors,          ficiency; respiratory disease).
  mainly in central nervous system; neuro-       •   Parasomnia (e.g., endocrine disorders, dia-
  logical disorder such as Huntington’s              betes mellitus, vascular disorder, neural
  Chorea, Parkinson’s disease, palsy, sub-           disorders, epileptic seizures).
  dural hematoma; nutritional deficiencies;
  vascular disorders; toxicities; head
  trauma).                                       ADDITIONAL HINTS TO IDENTIFY THE NEED
• Generalized Anxiety (e.g., cardiovascular      FOR MEDICAL REFERRAL
  disease such as arrhythmias, coronary
  artery disease, hypertension, mitral valve     Beyond using symptoms, several hints help
  prolapse; respiratory disease such as          identify the need for medical referral. When
  asthma, hyperventilation, chronic obstruc-     a client presents with inconsistent symptoms,
  tive lung disease, pulmonary embolus;          physical disorder needs to be suspected.
  endocrine/metabolic disorders such as hy-      For example, if a client complains of fatigue,
  poglycemia, hyper- or hypothyroidism, hy-      lack of appetite, and sexual disinterest, but
  ponatremia; neurological disorders such as     claims no other symptoms consistent with
12     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

depressive disorder, medical evaluation is in-         counselor requests a release of information
dicated given the lack of consistency to sup-          (ROI) from the client to access this medical in-
port a pure psychiatric diagnosis of depression        formation. Only a medical provider can make a
(i.e., never use “atypical” diagnoses without          medical diagnosis, especially as many differ-
medical corroboration). When a client who has          ential diagnoses rely not solely on a simple
been seen for a while suddenly develops new,           medical exam, but require in-depth and pro-
more, or more severe symptoms, a medical referral      tracted medical testing and evaluation. Table
is warranted. Morrison (1997) warns that               2.1, based on Morrison’s (1997) When Psycho-
counselors must “think outside the mental              logical Problems Mask Medical Disorders and
health box” (p. 2), especially with clients they       Klonoff and Landrine’s (1997) Preventing Mis-
have seen for some time. When sudden symp-             diagnosis of Women, lists the most common
tomatic changes occur, it is the responsibility        physical disorders with psychological manifes-
of the counselor to begin to question whether          tations and actions necessary to rule them out.
the pure mental health diagnosis truly ac-             Knowing which medical tests are typically
counts for the entire clinical picture. Another        used helps counselors decide whether the
cue to the need for medical referral can be            client’s medical exam targeted the current pre-
unusual or changing appearance or mannerisms           senting symptoms. This is necessary to con-
(Morrison, 1997). Examples include features            firm that at the time of the physical exam the
such as premature or nonmale pattern thin-             medical professional was aware of the psycho-
ning of hair (e.g., hypothyroidism, malnutri-          logical symptoms and ruled out the relevant
tion, or liver failure), darkening of skin (e.g.,      medical issues. This thoroughness is sug-
adrenal insufficiency or hypothyroidism), stiff        gested because not all clients are truthful and
or halting movements (e.g., fibromyalgia or            not all medical providers are equally qualified.
Creutzfeldt-Jakob disease), shortness of breath            The referral process itself is straightfor-
(e.g., B1 deficiency or congestive heart failure),     ward. The client is made aware of the need for
or tremors (e.g., Parkinson’s disease, multiple        the medical referral, prepared for the medical
sclerosis, or hypoglycemia). Any alarming              contact, given a referral name if he or she does
symptoms, such as blood in sputum or stool,            not have a regular medical provider, and asked
persistent headaches, or similar severe or sud-        to sign an ROI to allow communication be-
den physical manifestations also always war-           tween the medical provider and counselor.
rant medical referral, even if the client does         When making referrals to physicians, physi-
not connect them to the psychological present-         cian’s assistants, nutritionists, nurse practi-
ing symptoms. Klonoff and Landrine (1997)              tioners, and so forth, counselors have the
suggest that “visual illusions or hallucinations al-   responsibility to coordinate and facilitate this
ways have an organic, rather than functional or        process for their clients. To prepare for their
psychiatric, etiology” (p. 59), and hence always       role as facilitators, counselors should enhance
require a medical referral. In fact, these au-         communication with physicians. First, it is rec-
thors indicate that basic physical exams should        ommended that counselors identify medical spe-
be required of all psychotherapy clients. Fi-          cialists with whom they can collaborate easily.
nally, when in doubt, refer.                           Klonoff and Landrine (1997) recommend that
                                                       this list optimally include an endocrinologist,
                                                       a neurologist, a gynecologist, and an internist.
FEATURES OF THE SUCCESSFUL                             Counselors need to be prepared to provide hy-
REFERRAL PROCESS                                       potheses about what might be going on with the
                                                       client, providing concrete ideas of differential
If a client meets a criterion for medical refer-       diagnoses based on physical data. To do
ral, counselors need to explore whether the            so, they need to learn basic medical jargon that
client received a recent (within the past one to       allows for communication and engenders re-
three months) medical evaluation that as-              spect. Medical providers will take a nonmed-
sessed relevant medical disorders. If so, the          ical referral source more seriously if he or she
                           2 • COUNSELING CLIENTS WITH UNDERLYING MEDICAL PROBLEMS                                      13

TABLE 2.1       Physical Disorders with Psychological Symptoms

         Disorder              Psychological Symptoms             Physical Symptoms                Medical Tests

Adrenal insufficiency         Fatigue, apathy,                Weakness, darkening skin,      History of salt cravings,
(Addison’s disease)           depression, social              nausea, abdominal pain,        urine or sputum test
                              withdrawal, anxiety,            fainting, vomiting, weight     measuring cortisol levels
                              suicidality, psychosis,         loss, anorexia (loss of
                              poverty of thought, recent      appetite)
                              memory impairment
Amyotropic lateral            Depression, dementia            Muscle weakness, weight        Electromyography (to
sclerosis (Lou Gehrig’s                                       loss, ataxia (inability to     show muscle twitching)
disease)                                                      coordinate voluntary
                                                              muscle movement),
                                                              dysarthria (inability to
                                                              articulate words),
                                                              cramping

Brain abscess                 Lethargy, cognitive             Headache, fever, stiff neck,   CT scan, MRI
                              changes and symptoms            seizures, nausea,
                                                              vomiting, focal
                                                              neurological symptoms
Brain tumor                   Loss of memory, cognitive       Headaches, vomiting,           CT scan, MRI, brain
                              changes, dementia,              dizziness, seizures, focal     biopsy
                              depression, psychosis,          neurological symptoms
                              dissociation, personality
                              changes

Carcinoid syndrome            Flushing of the face and        Diarrhea, abdominal pain,      Urine sample to assess
                              body ( blushing)                blood-containing stool         high levels of serotonin
                                                                                             breakdown products
Cardiac arrhythmia            Anxiety, delirium               Fatigue, dizziness,            Electrocardiogram
                                                              delirium, palpitations

Chronic obstructive lung      Anxiety, panic,                 Cough, shortness of            Pulmonary function
disease                       depression, insomnia,           breath, tremor, headache,      studies, blood-gas
                              delirium                        dark skin hue                  determination

Congestive heart failure      Anxiety, panic, insomnia,       Shortness of breath,           Chest X-ray,
                              delirium, depression            fatigue, edema, cold,          echocardiogram
                                                              weakness, cyanosis

Cryptococcus                  Irritability, disorientation,   Headache, fever, stiff neck,   Search for causative yeast
                              mania, dementia,                blurred vision, nausea,        organism in cerebrospinal
                              psychosis                       staggering gait                f luid bathed in india ink

Cushing’s syndrome            Emotional lability,             Hypertension,                  Physical exam,
                              depression, anxiety, loss of    amenorrhea (cessation of       corticosteroid level in
                              libido, delirium,               menstruation), oily skin,      24-hour urine specimen,
                              irritability, paranoid          increased body hair,           history of steroid-
                              delusion, suicidality (high     weakness, facial and           containing substances
                              risk)                           truncal obesity, buffalo
                                                              hump

Diabetes mellitus             Fatigue, lethargy, panic,       Increased hunger, thirst,      At least two abnormal
                              depression, poor                and urine output; rapid        glucose tolerance tests
                              concentration, delirium         weight loss; blurred vision

Fibromyalgia                  Chronic fatigue,                Muscle pain, stiffness, and    By history and symptom
                              depression, anxiety             tenderness                     presentation

                                                                                                              (continued)
14      PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

TABLE 2.1     Continued

         Disorder          Psychological Symptoms           Physical Symptoms                 Medical Tests

Head trauma               Personality change,           Headache, dizziness,           Skull X-ray, MRI, CT scan
                          delirium, dementia,           fatigue, paralysis,
                          amnesia, mood swings,         seizures, anosmia (loss of
                          psychosis, anxiety            sense of smell)

Herpes encephalitis       Forgetfulness, anxiety,       Fever, headache, stiff neck,   Electroencephalogram,
                          psychosis                     vomiting, focal                brain biopsy, CT scan
                                                        neurological symptoms

Homocystinuria            Mental retardation,           Impaired vision, shuff ling    Blood or urine test to
                          dementia, behavioral          gait, blotchy skin             check for elevated levels of
                          problems                                                     homocysteine and
                                                                                       methionine

Huntington’s disease      Apathy, depression,           Insomnia, restlessness,        Family history of this fatal
                          irritability, impulsive       ataxia, inarticulate speech,   disease, genetic testing
                          behavior, personality         good appetite with weight
                          changes, cognitive            loss, clumsiness, writhing
                          changes, suicidality,         motions of the limbs
                          dementia

Hyperparathyroidism       Personality change,           Urinary tract infections,      Blood test to establish
(Hypercalcemia)           depression, anxiety,          weakness, tiredness,           high serum calcium and
                          suicidality, delirium,        anorexia, nausea,              parathyroid hormone
                          psychosis; often mistaken     vomiting, thirst,              levels
                          for hypochondriasis           constipation, muscle and
                                                        abdominal pain

Hypertensive              Paranoia, delirium            Headache, nausea,              Measurement of blood
encephalopathy                                          paralysis, vomiting, visual    pressure (presence of
                                                        impairment, seizures           hypertension)

Hyperthyroidism           Agitated depression,          Goiter, red and puffy          Thyroid panel ( blood test)
                          depression, anxiety, panic,   eyelids, bulging eyes,         to check for elevation of
                          delirium, psychosis; often    weakness, palpitations,        serum thyroxine levels
                          mistaken for Bipolar          hunger, tremor, warm,          and drop in thyroid
                          Disorder                      increased appetite with        stimulating hormone
                                                        weight loss, diarrhea
Hypoglycemia              Anxiety,                      Sweating, palpitations,        Food diary, 5-hour fasting
                          depersonalization,            tremulousness, headache,       glucose tolerance test
                          lethargy, fatigue             confusion

Hypoparathyroidism        Irritability, mental          Numbness, tingling, and        Blood test to establish low
(Hypocalcemia)            retardation, depression,      spasms in hands, feet, and     serum calcium and
                          anxiety, paranoia,            throat; headaches; thin,       parathyroid hormone
                          delirium, dementia            patchy hair; poor tooth        levels
                                                        development

Hypopituitarism           Apathy, indifference,         Waxy skin, loss of body        X-ray, CT scan, or MRI to
                          fatigue, depression,          hair, inability to tan, loss   establish structural
                          decreased libido,             of appetite and weight, loss   pituitary abnormality;
                          drowsiness; often             of nipple pigmentation,        blood test to establish
                          mistaken for Dependent        premature wrinkles             hormonal deficiencies
                          Personality Disorder or       around eyes and mouth
                          psychotic depression
                           2 • COUNSELING CLIENTS WITH UNDERLYING MEDICAL PROBLEMS                                  15

TABLE 2.1      Continued

         Disorder              Psychological Symptoms          Physical Symptoms                 Medical Tests

Hypothyroidism                Apathy, depression,          Dry and brittle hair, dry       Blood test to establish
                              suicidality, slowed          skin, hair loss, edema, cold    drop in serum thyroxine
                              cognitive function,          intolerance, appetite loss      and elevation in thyroid
                              dementia; mistaken for       with weight gain, goiter,       stimulating hormone
                              rapid-cycling Bipolar        constipation, hoarseness,       levels; measurement of
                              Disorder                     hearing loss, slow              basal body temperature on
                                                           heartbeat                       five consecutive mornings
Lyme disease                  Depression, psychosis,       Headache, fever, chills,        History of tick bite, serum
                              anxiety, mild cognitive      fatigue, stiff neck, malaise,   antibody response to
                              symptoms                     achiness                        B. Burgdorferi

Meniere’s syndrome            Anxiety, panic,              Dizziness, nausea,              Diagnosis based on
                              depression, poor             vomiting, tinnitus              symptoms
                              concentration                (ringing in the ears),
                                                           nystagmus (rapid,
                                                           involuntary eyeball
                                                           oscillation), deafness

Mitral valve prolapse         Panic (do not use            Chest pain, fainting,           Echocardiogram
                              anxiolytics)                 palpitations,
                                                           breathlessness

Multiple sclerosis            Depression, mania, sudden    Ataxia, numbness,               MRI to show areas of
                              emotionality, cognitive      weakness, fatigue, visual       plaque; birthplace north of
                              impairment, dementia;        problems, incontinence,         55˚ latitude; hot bath test
                              misdiagnosed as              trouble walking,                (weakness and faintness
                              somatization or Histrionic   paresthesias (tingling or       after hot bath)
                              Personality Disorder         prickling of skin)

Myasthenia gravis             Anxiety, memory loss,        Muscle weakness                 Tensilon test (injection of
                              minor cognitive symptoms                                     edrophonium to check for
                                                                                           brief ly improved muscle
                                                                                           strength)

Niacin deficiency             Depression, anxiety,         Weakness, anorexia,             Food diary, based on
(Pellagra)                    delirium, dementia           headache, diarrhea, red         symptoms, urine test
                                                           and rough skin

Pancreatic cancer             Depression, initial          Weight loss, weakness,          Ultrasound, CT scan, or
                              insomnia, crying spells,     abdominal pain, insomnia,       endoscopic retrograde
                              suicidality, anxiety,        hypersomnia                     pancreatography; needle
                              hypersomnia                                                  biopsy

Parkinson’s disease           Depression, anxiety,         Tremor, muscle rigidity,        Based on symptoms and
                              impaired attention,          decreased mobility,             physical exam
                              cognitive deficits,          masked facies, trouble
                              paranoia; visual             walking, poor fine motor
                              hallucinations as side       coordination
                              effect of medications

Pernicious anemia             Forgetfulness, depression,   Anemia, dizziness,              Blood test
                              dementia, psychosis          tinnitus, glossy tongue,
                                                           palpitations

Pheochromocytoma              Anxiety, panic               Headache, sweating,             24-hour urine test for high
                                                           palpitations, nausea, high      catecholamine levels
                                                           blood pressure

                                                                                                            (continued)
  16        PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

TABLE 2.1       Continued

           Disorder                 Psychological Symptoms                Physical Symptoms                     Medical Tests

Porphyria                          Depression, mania,                 Abdominal pain, muscle             Blood or urine test to
                                   euphoria, anxiety,                 weakness, tremors, dark            check for high levels of
                                   delirium, psychosis                urine, vomiting, seizures,         porphobilinogen
                                                                      sweating

Posterolateral sclerosis           Anxiety, weakness,                 Heavy limbs, stocking              Electromyography
                                   memory impairment,                 and/or glove sensory loss,
                                   psychosis; mistaken for            alteration in ref lexes
                                   Conversion Disorder

Prion disease                      Anxiety, fatigue, poor             Difficulty walking,                Electroencephalogram,
                                   concentration, slowed              tremors, muscle rigidity,          history of ingestion of
                                   mental function                    hypokinesia (decreased             infected meat
                                                                      muscle movement)

Progressive supranuclear           Slowed mental function,            Double vision, unsteady            CT scan showing atrophy
palsy                              forgetfulness, apathy,             gait, muscle stiffening            of pons and midbrain
                                   labile mood

Protein energy                     Apathy, lethargy, cognitive        Weight loss; loss of skin          Food diary, physical exam,
malnutrition                       changes                            elasticity; dry, thin hair;        blood test for low serum
                                                                      low body temperature,              protein levels
                                                                      heart rate, and blood
                                                                      pressure

Sleep apnea                        Insomnia, depression,              Snoring, morning                   Sleep polysomnography
                                   drowsiness, irritability,          headache, nocturia
                                   poor concentration                 (nighttime urination)

Syphilis                           Personality changes,               Ulcerous chancre, fever,           Serum screening test and
                                   fatigue, irritability,             headache, sore throat, skin        serum f luorescent
                                   grandiosity, cognitive             rash, swollen lymph nodes          treponeme antibody
                                   symptoms, psychosis                                                   absorption test

Systemic lupus                     Severe depression,                 Muscle and joint pain,             Blood test to establish
erythematosus                      cognitive symptoms,                butterf ly rash, fatigue,          elevation of antinuclear
                                   anorexia, psychosis                fever, loss of appetite,           antibodies
                                   (thorazine exacerbates             nausea, vomiting, weight
                                   symptoms)                          loss

Thiamine deficiency                Fatigue, irritability,             Shortness of breath,               History of alcoholism,
(Beriberi)                         anxiety, delirium, amnesia         edema, rapid heartbeat,            food diary, MRI, CT scan,
                                                                      nystagmus, trouble                 blood/urine tests
                                                                      walking, fever, vomiting

Wilson’s disease (Inherited        Anxiety, personality               Dysarthria, tremor,                Liver function test (excess
copper toxicosis)                  change, irritability, anger,       spasticity, rigidity, trouble      copper), blood tests
                                   loss of inhibition,                swallowing, dystonia               (deficient copper-protein
                                   psychosis, depression,             (poor tonicity of tissue),         ceruloplasmin), MRI, CT
                                   cognitive symptoms                 drooling                           scan

Source: From Dealing with Challenges in Psychotherapy and Counseling, 1st ed., by C. Brems © 2000. Reprinted with permission of Wadsworth,
an imprint of Wadsworth Group, a division of Thomson Learning. Fax (800) 730-2215.



refers to the client as patient (Klonoff & Lan-                         consists of information such as weight pat-
drine, 1997). Obtaining basic preliminary physi-                        terns, sleep patterns, changes in physical func-
cal data from the client also expedites the                             tioning, substance use, and specific physical
referral and increases the likelihood of correct                        symptoms and their context (Brems, 1999). The
medical diagnosis. Preliminary physical data                            more physical data counselors can offer, the
may be gleaned through an interview and                                 more seriously they and the referral will be
                     2 • COUNSELING CLIENTS WITH UNDERLYING MEDICAL PROBLEMS                           17

taken by the physician (Klonoff & Landrine,          and chronicity of the medical illness. Close
1997). Presenting this wealth of medical infor-      monitoring of the client’s physical condition
mation in the most concise and brief manner, as      will be necessary, as will the counselor’s need
opposed to embedded in a lengthy psychoso-           to learn more about the client’s particular ill-
cial history, will reap the greatest benefit (Dia-   ness. Again, collaboration with the medical
mond, 1998). Finally, it is important that           provider in this regard is emphasized.
counselors never pretend to understand informa-
tion when in reality they do not. Asking ques-       References
tions to be informed about clients’ medical
conditions and the medical tests they may be         Brems, C. (1999). Psychotherapy: Processes and tech-
facing is essential for optimal rapport. If coun-        niques. Boston: Allyn & Bacon.
                                                     Brems, C. (2000). Dealing with challenges in psy-
selors do not understand what their clients
                                                         chotherapy and counseling. Pacific Grove, CA:
will encounter, they cannot help them prepare.
                                                         Brooks/Cole.
                                                     Diamond, R.J. (1998). Instant psychopharmacology: A
                                                         guide for the nonmedical mental health profes-
PLANNING TREATMENT AFTER A                               sional. New York: Norton.
COMPLETED MEDICAL REFERRAL                           Klonoff, E.A., & Landrine, H. (1997). Preventing
                                                         misdiagnosis of women: A guide to physical disor-
If the medical provider rules out physical or            ders that have psychiatric symptoms. Thousand
medical causes for the client’s presenting con-          Oaks, CA: Sage.
cerns, the counselor makes a proper mental           Morrison, J. (1997). When psychological problems
                                                         mask medical disorders: A guide for psychothera-
health treatment plan focusing on the client’s
                                                         pists. New York: Guilford Press.
psychological symptoms, comfortable in the
                                                     Samson, J.A., Levin, R.M., & Richardson, G.S.
knowledge that no medical concerns are                   (1998). Psychological symptoms in endocrine
present. If, however, an underlying medical              disorders. In P.M. Kleespies (Ed.), Emergencies
diagnosis completely or partially causes the             in mental health practice (pp. 332–354). New
psychological symptoms, counselor and                    York: Guilford Press.
physician collaborate to determine the opti-         Tomb, D.A. (1995). Psychiatry. Baltimore: Williams
mal course of action. Medical symptoms are               & Wilkins.
best treated by the medical provider; however,       White, R.F., Marans, K.S., & Krengel, M. (1998).
the sequellae of having a medical disorder that          Psychological/behavioral       symptoms        in
has emotional consequences are best treated              neurological disorders. In P.M. Kleespies
                                                         (Ed.), Emergencies in mental health practice
by the counselor. Psychological treatment with
                                                         (pp. 312–331). New York: Guilford Press.
a client who has an underlying medical ill-
                                                     Wickramasekera, I., Davies, T.E., & Davies, S.M.
ness will be different from counseling a client          (1996). Applied psychophysiology: A bridge
with psychological symptoms without med-                 between the biomedical model and the
ical causes. For the client with both concerns,          biopsychosocial model in family medicine.
counseling requires different goals and will             Professional Psychology: Research and Practice,
largely be influenced by the severity, acuity,           27, 221–233.
                  COUNSELING WITH
       3          UNEMPLOYED AND
                  UNDEREMPLOYED CLIENTS


                  Ellen B. Lent



     And when we have time on our hands,                    following categories: internal, or unique to the
     We have a pastime                                      person; and external, including availability of
     Wherein we try to have a good time,                    work, development opportunities, bias and
     Even a grand time,                                     other unjust barriers related to clients’ demo-
     Or perhaps the time of our life.                       graphic features, and access to technology.
                              (Bolles, 2000, p. xii)


In the best of all worlds, our work is the time             INTERNAL ISSUES
of our life. The emotional experience of satis-
fying work may protect us from negative men-                Factors often included in models of job and
tal health outcomes and physical health                     career psychology include interests, values,
complaints (Lent, 1995). When work fails to be              skills, decisiveness, and maturity. When a
the time of our clients’ lives, a counseling in-            client is at liberty to choose among available
tervention may be useful. The purpose of this               and attractive work options, these factors can
chapter is to focus attention on what is known              be very useful in counseling. However, when
about responsible and ethical practices in                  clients are in distress about work, additional
counseling adult clients who have lost a job or             internal factors such as well-being, self-
who complain of being underemployed.                        efficacy, work strain, and other emotional and
    Underemployment is defined here as less-                cognitive stressors may be more prominent.
than-optimum use of an individual’s capacities                  Well-being is defined as the belief that one
at work. Possible companions of underemploy-                is living a good and worthwhile life, accompa-
ment include boredom and loss of dignity                    nied by the presence of positive feelings and
(Hansen, 1997), uncertainty (Landy, 1992),                  the relative absence of negative feelings (Di-
anxiety (Osipow & Fitzgerald, 1996), and low                ener, 2000). Job satisfaction is a component of
self-confidence (Shullman & Carder, 1983). De-              well-being. Satisfaction with one’s job, more
pression, anxiety, substance use, and other un-             than working conditions or supervision, may
wanted behaviors have been seen with chronic                be closely related to clients’ mental health
and acute joblessness and job dissatisfaction               (Osipow & Fitzgerald, 1996).
(Locke & Latham, 1990). Unwanted unemploy-                      A facet of well-being relevant to work roles
ment and underemployment can themselves be                  is the ability to be flexible in setting goals. Be-
life stressors and can reduce people’s ability to           cause becoming and staying employed relies
handle other stressors. In addition, the absence            partly on factors outside of one’s individual
of income is an important stressor for most un-             control, the willingness to adjust and change
employed clients.                                           goals is an important factor in difficult cir-
    Concepts related to unemployed and un-                  cumstances (Diener, 2000). How people adapt
deremployed individuals fall into one of the                to changing conditions helps to indicate their

                                                       18
                   3 • COUNSELING WITH UNEMPLOYED AND UNDEREMPLOYED CLIENTS                           19

ability to benefit from counseling and reach              job or chronic underemployment may be
their goals.                                              stressful enough to contribute to a depressed
    Clients’ level of self-efficacy, or belief in their   or anxious mood, behavior disruptions, and
ability to complete certain actions, can indi-            other negative symptoms.
cate their willingness to engage in a job search.            The state of being employed can itself be
They may doubt their own competence and                   significant: “Almost any type of work, regard-
worth and question their ability to find a new            less of how much of an underload or overload
job or improve their present working condi-               it represents, has the capacity to relieve de-
tions. Underemployed clients may believe that             pression in some people” (Landy, 1992, p. 137).
their talents are not valued. Job search self-            Unemployment can precipitate depression,
efficacy has been found to predict actual job             anxiety, substance abuse, and other serious
searching better than general self-esteem and             disorders in some people.
sense of control (Saks & Ashforth, 1999). The                For clients experiencing an unwanted job
setting of specific goals and a belief in positive        loss or chronic underemployment, searching
outcomes are important aspects of job search              for a new position may propel them into
self-efficacy that may help predict the success           counseling. After issues such as those above
of counseling interventions.                              are resolved or ruled out, general factors in
    Reduced self-efficacy and self-esteem can             job transition are useful to address.
interfere with individuals’ plans to identify
and act on their interests in the workplace
                                                          Interests
(Betz, 1999). If clients are not confident of their
“match” with particular jobs or work settings,            There is a huge literature on assessing and
they risk giving up in the face of barriers such          measuring vocational interests, underscoring
as discrimination or lack of training.                    the perceived importance of interests when
    Work strain refers to problems with work              counseling adults on work transitions. Inter-
tasks, demands, and relationships. It can in-             ests are measured by a variety of available in-
clude being over- or underworked; having con-             ventories that can help clients to “focus
flict in work relationships, feeling unprepared           attention, arouse feelings, and steer a direc-
for new work tasks, and having multiple de-               tion” (Savickas & Spokane, 1999, p. 6). The re-
mands at work and in other life roles. Workers            liability and validity of interest inventories
with outdated skills may describe being un-               for various cultural and ethnic groups is still
derutilized or bored. Clients may sometimes               under study. Interests can also be assessed by
report lack of interest when they are actually            card sorts and other methods of self-report
feeling depressed or anxious about their work             (cf. Peterson, 1998). Research has amply
or the upcoming job search. Use of caffeine               demonstrated their stability—and there is a
and nicotine may alleviate boredom due to mo-             strong genetic component to individual inter-
notonous work tasks (Landy, 1992).                        ests (cf. Betsworth & Fouad, 1997; Swanson &
                                                          Gore, 2000)—but it is not yet known how
                                                          much change in interests is possible over
Other Emotional and Cognitive Stressors
                                                          time and across different activity settings.
A significant proportion of recipients of public          Understanding clients’ interests does not tell
assistance are homeless, have chronic physical            the entire story in a counseling intervention.
or mental health problems or drug or alcohol              Individual values are also important factors
problems, and are survivors of serious abuse              in work transition. Status, comfort, and
(Edwards, Rachal, & Dixon, 1999). Intellectual            safety may rank higher than altruism,
and cognitive deficits may be present as well.            achievement, and autonomy in a job change
Because many of these adults are now entering             decision, citing one set of values often ap-
the workforce, it is more likely that counselors          plied to the work setting (Dawis & Lofquist,
will see these issues in clients presenting with          1984). The role of meaning in work also
employment concerns. In addition, the loss of a           plays a part in many people’s cognitive and
20     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

emotional responses to unwanted job loss or          global economy shift further toward informa-
underutilization.                                    tion technology and biotechnology and away
    People’s skill levels are often deduced by ex-   from manufacturing and many service occupa-
amining test scores, academic grades, letters of     tions. Two million white-collar jobs change
reference, and other unique indicators. Stan-        dramatically or disappear in the United States
dardized scores of aptitude and achievement          every year, and a significant number of blue-
are also used in some settings. Prediction of        collar jobs incorporate new levels of computer-
future job performance can be attempted by           related skills (Rifkin, 1995).
these means, but concerns exist about the ef-            Access to job networks and promotional oppor-
fects on disadvantaged job candidates (Osipow        tunities is a crucial factor relevant to counsel-
& Fitzgerald, 1996). The variable nature of          ing the unemployed and underemployed. Bias,
performance appraisals in the workplace, with        discrimination, and other barriers can affect a
multiple raters of uncertain quality and moti-       significant proportion of hopeful workers. Per-
vation, makes skill level a factor that may          sons of low social class represent one such vul-
straddle internal and external categories. It is     nerable group. A home address from a poor
clear, however, that ability and skill feed-         neighborhood can destine a job application for
back contributes importantly to people’s self-       the recycling bin (Wilson, 1996). Discrimina-
concepts and beliefs about their work interests      tion on the basis of age, gender, race, disability,
and choices.                                         sexual orientation, and other demographics
    The level of decidedness with which clients      renders many others vulnerable as well. These
approach job and career choice has received          conditions can lower self-efficacy and expecta-
significant attention. Less is known about the       tions for success.
role of decidedness in adults who have been              Access to learning and new skill development is
employed but are seeking a new job. Theories         crucial to remaining employable and having a
of coping methods in responding to chronic           positive work experience. Persons reporting
stress include an emphasis on decision mak-          no on-the-job development, training, or learn-
ing (cf. Folkman & Moskowitz, 2000). Indeci-         ing are at risk of unemployment or underem-
siveness can signal emotional conflicts or           ployment due to skill obsolescence.
obstacles to making choices (Savickas, 1996).            Technology access increasingly dictates the
Self-efficacy for making decisions can help or       amount of job information available and the
hinder the process; for instance, beliefs in         speed with which it is obtained. Many poten-
one’s ability to find acceptable job options         tial employers request resumes strictly by elec-
and choose among them predicts employ-               tronic transmission, containing key words that
ment (Saks & Ashforth, 1999).                        are recognizable by computer programs that
    A well-known definition of vocational matu-      route them to the most appropriate recipient.
rity encompasses a number of tasks relevant          With sufficient economic means, people can
to choosing an occupation or work setting.           subscribe to services that remotely search job
Defined by Donald Super and his colleagues,          listings throughout the World Wide Web, de-
it includes an evaluation of interests, behav-       livering the most relevant openings directly to
iors, values, and knowledge said to aid in vo-       their e-mail address on a daily basis. Clients
cational planning and choice (Thompson,              with little or no technology access may be left
Lindeman, Super, Jordaan, & Myers, 1981).            out of this avenue of job searching.
                                                         Social support has been shown to reduce the
                                                     effects of stress in many different domains.
EXTERNAL ISSUES                                      Gaining the support of important others is a
                                                     significant aspect of lessening the stress and
A variety of factors external to clients may im-     overcoming the barriers of underemployment
pact on counseling assessment and treatment.         and unemployment. It has been suggested
Availability of work is relevant to everyone, but    that aiding clients in finding and gathering
is even more important as the U.S. and the           supportive others yields more benefit than
                 3 • COUNSELING WITH UNEMPLOYED AND UNDEREMPLOYED CLIENTS                         21

focusing on removing barriers in job search         career, and life satisfaction in a changing
and work transitions (Brown & Krane, 2000).         society” (Brown & Krane, 2000, p. 740). A
                                                    client-centered assessment aids in under-
                                                    standing the full scope of clients’ needs,
COUNSELING PROCESS FACTORS                          goals, satisfiers, and interests in the world of
                                                    work. It can also encourage discussion of ex-
What counselors bring to the counseling rela-       ternal and internal obstacles that may be
tionship—their assumptions, values, methods,        holding clients back from feeling confident
and intervention choices—deserve mention in         and taking action. Counselors can evaluate
this discussion. Evaluating clients nondirec-       sense of competence or self-efficacy by ask-
tively aids in keeping counselor biases and         ing clients if they believe they can perform
assumptions at a minimum (Lent, 1996). Struc-       actual job search behaviors, such as revising
tural obstacles such as discrimination must be      a resume or finding job leads. This can lead
explored from the client’s perspective. The         to specific action steps that should improve
type of intervention recommended may be             clients’ belief in their abilities.
highly informational, highly therapeutic, or a         Counselors can initiate discussion of bias,
combination of both. Counselors may find that       discrimination, and other societal obstacles in
collaboration with bachelor’s-level career de-      their assessment. Expectations about salary,
velopment facilitators (Splete & Hoppin, 2000)      benefits, promotion and training opportuni-
and other trained personnel works to their ad-      ties, and level of autonomy or responsibility
vantage in efficient provision of services.         may be affected by clients’ social class, race,
   Confidentiality and privacy must be clearly      gender, age, and other demographic features.
described and carefully guarded, especially            Many clients seeking work transition
when telephone or computer lines are involved       counseling expect to be given testing, which
(including telephone counseling and coaching        will indicate their best work choices. Placing
and inventories completed via Web sites). The       responsibility for this process on an external
validity and reliability of inventories and other   resource can be indicative of anxiety regard-
instruments must be determined and delivered        ing the task. Because a major cause of early
by those trained and competent in their use.        termination from career counseling is anxi-
   There is some evidence that in establishing      ety, it is advisable to engage clients in a thor-
and maintaining a counseling relationship, the      ough assessment and explore potential
focus on a specific task and goals for clients to   emotional barriers before embarking on a
accomplish is of greater import than a thera-       structured exploration of interests, skills,
peutic bond between counselor and client            and work values. At the end of this process,
(Warwar & Greenberg, 2000). On the other            the match between clients’ needs and talents
hand, a resurgence of interest in therapeutic       should be maximized, “so that their aspira-
empathy encourages focus on counselor-client        tions are aimed as high as their ability will
interactions. Narrative counseling techniques       take them” (Brown & Krane, 2000, p. 751).
highlight the stories that clients tell and sug-
gest methods for actively “writing” new por-
                                                    Two Notes of Caution
tions in the context of counseling.
                                                    Clients may inform you that they have com-
                                                    pleted career inventories on the Internet and
COUNSELING RECOMMENDATIONS                          that they have taken action based on the re-
                                                    sults. Remote administration of these instru-
One definition of counseling for work con-          ments can be fraught with pitfalls (cf.
cerns encompasses a number of the themes            Sampson & Lumsden, 2000):
mentioned in this chapter: “Helping people
make goal-congruent work or career choices          • Clients’ unique issues may not have been
that will allow them to experience work,              assessed initially.
22      PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

• The norm groups for the instrument may             Satisfaction Scale (Holland & Gottfredson,
  not represent the client demographically.          1994).
• The person who administered or scored the          Career Decision-Making Self-Efficacy
  instrument may not be adequately trained.          Scale (Betz, Klein, & Taylor, 1996).
• Clients may have completed the instrument
                                                     Kuder Career Search (Zytowski, 1999).
  in an environment not conducive to reliable
  results; for instance, with interruptions or       Myers-Briggs Type Indicator (Myers, Mc-
  other challenges to concentration.                 Caulley, Quenk, & Hammer, 1998).
• Clients’ privacy may not have been pro-            Occupational Stress Inventory (Osipow &
  tected, and they may begin to receive un-          Spokane, 1987).
  solicited marketing materials linked to            Self-Directed Search (Holland, 1994).
  their individual responses.
                                                     Strong Interest Inventory (Strong, Hansen,
• The inventory results might not have been
                                                     & Campbell, 1994).
  reported in a way that allowed clients’ full
  understanding or follow-up discussion.
                                                      Card sorts offer another structured way
                                                   for counselors and clients to explore occupa-
   A second cautionary topic is the unan-
                                                   tional interests. Manipulating cards with oc-
swered question of the long-term usefulness
                                                   cupational titles can provide a novel activity
of counseling adults in work transitions.
                                                   in the counseling process. The following titles
Studies have shown that people using coun-
                                                   may be useful:
seling and allied services are more satisfied
with job choice, values clarification, and other
                                                     Deal Me In Cards (Farren, Kaye, & Lei-
immediate outcomes. However, research has
                                                     bowitz, 1985).
not effectively demonstrated that people who
obtain career or job counseling are more satis-      Occupational Interest Card Sort (Knowdell,
fied with their work, their life, or other re-       1993).
lated outcomes in the long run (Brown &              Missouri Occupational Card Sort (Krieshok,
Krane, 2000). This question deserves further         Hansen, & Johnston, 1989).
study to determine the ideal amount of effort        Slaney Vocational Card Sort (Slaney, 1978).
that should be expended on program design,
                                                     Vocational Exploration and Insight Kit
counseling processes, structured activities
                                                     (Holland & Associates, 1980).
and instruments, and other services designed
to help people have the time of their lives in       Other resources worthy of attention follow:
the workplace.
                                                     Careerhub: www.careerhub.org. This Web
Tests and Inventories                                site was designed in consultation with
                                                     the University of California, Berkeley, as a
Published instruments often enrich the coun-         stand-alone resource for career and job
seling process for clients who have minimal          searchers. It offers free inventories that do
conflicts and obstacles. Among the many in-          not require a trained counselor’s interpre-
struments in use for adults making work tran-        tation and provides guidance on when to
sitions, the following titles may be useful          seek a counselor. Access to copyrighted
after a careful assessment:                          instruments and materials is available for
                                                     a fee.
     Adult Career Concerns Inventory (Super,
                                                     Joint special issue, The Career Development
     Thompson, & Lindeman (1987).
                                                     Quarterly and The Journal of Employment
     Campbell Interests and Skills Survey            Counseling: Collaboration, Partnership, Pol-
     (Campbell, 1994).                               icy, and Practice in Career Development.
     Career Attitudes and Strategies Inven-          48, June 2000: National Career Develop-
     tory—Career Obstacles Checklist and Job         ment Association.
                   3 • COUNSELING WITH UNEMPLOYED AND UNDEREMPLOYED CLIENTS                                    23

   Special issue, Journal of Career Assessment:           Campbell, D.P. (1994). The Campbell Interests and
   Career Assessment and the Internet. 8,                      Skills Survey. Minneapolis, MN: National
   Winter 2000: Psychological Assessment Re-                   Computer Systems.
   sources, Inc.                                          Dawis, R.V., & Lofquist, L.H. (1984). A psychological
                                                               theory of work adjustment: An individual-differ-
   Handbook of Career Counseling Theory and                    ences model and its applications. Minneapolis:
   Practice (2000). Edited by M.L. Savickas and                University of Minnesota Press.
   W.B. Walsh. Palo Alto: Davies-Black.                   Diener, E. (2000). Subjective well-being: The sci-
   What Color Is Your Parachute? (2000). Richard               ence of happiness and a proposal for a na-
   Bolles. Berkeley, CA: Ten Speed Press.                      tional index. American Psychologist, 55, 34 – 43.
                                                          Edwards, S.A., Rachal, K.C., & Dixon, D.N. (1999).
                                                               Counseling psychology and welfare reform:
                                                               Implications and opportunities. The Counsel-
SUMMARY
                                                               ing Psychologist, 27, 263 –284.
                                                          Farren, C., Kaye, B., & Leibowitz, Z. (1985). Deal me
Clients can report significant difficulty facing               in. Silver Spring, MD: Career Systems.
the stressors of underemployment or unem-                 Folkman, S., & Moskowitz, J.T. (2000). Positive af-
ployment. Although not enough is known                         fect and the other side of coping. American
about the long-term effects of counseling for                  Psychologist, 55, 647–654.
these issues, it is highly desirable to do a com-         Hansen, L.S. (1997). Integrative life planning: Critical
plete assessment and intervene promptly, ad-                   tasks for career development and changing life pat-
dressing both internal and external factors                    terns. San Francisco: Jossey-Bass.
related to work transitions. When emotion-                Holland, J.L. (1994). Self-directed search. Odessa, FL:
                                                               Psychological Assessment Resources.
ally ready, clients can benefit from structured
                                                          Holland, J.L., & Gottfredson, G.D. (1994). Career
adjuncts in counseling and targeted discus-
                                                               Attitudes and Strategies Inventory: An inventory
sion of supports and obstacles to achieving                    for understanding adult careers. Odessa, FL: Psy-
satisfaction in their work lives.                              chological Assessment Resources.
                                                          Holland, J.L., & Associates. (1980). Counselor’s
                                                               guide to the Vocational Exploration and Insight Kit
References
                                                               (VEIK). Palo Alto, CA: Consulting Psycholo-
Bettsworth, D.G., & Fouad, N.A. (1997). Vocational             gists Press.
     interests: A look at the past 70 years and a         Knowdell, R.L. (1993). Manual for Occupational In-
     glance at the future. Career Development Quar-            terests Card Sort Kit. San Jose, CA: Career Re-
     terly, 46, 23 – 47.                                       search and Testing.
Betz, N.E. (1999). Getting clients to act on their        Krieshok, T.S., Hansen, R.N., & Johnston, J.A.
     interests: Self-efficacy as a mediator of the             (1989). Missouri Occupational Card Sort manual.
     implementation of vocational interests. In                Columbia: University of Missouri, Career Plan-
     M.L. Savickas & A.R. Spokane (Eds.), Voca-                ning and Placement Center.
     tional interests: Meaning, measurement and           Landy, F.J. (1992). Work design and stress. In
     counseling use (pp. 327–344). Palo Alto, CA:              G.P. Keita & S.L. Sauter (Eds.), Work and well-
     Davies-Black.                                             being: An agenda for the 1990s (pp. 119–158).
Betz, N.E., Klein, K.L., & Taylor, K.M. (1996). Eval-          Washington, DC: American Psychological
     uation of a short form of the Career Decision-            Association.
     Making Self-Efficacy Scale. Journal of Career        Lent, E.B. (1995, August). Worklife efficacy: Preven-
     Assessment, 1, 21–34.                                     tion and intervention. Paper presented at the
Bolles, R.N. (2000). What color is your parachute? A           third conference on Work Stress and Health,
     practical manual for job-hunters and career-chang-        American Psychological Association and Na-
     ers. Berkeley, CA: Ten Speed Press.                       tional Institute for Occupational Safety and
Brown, S.E., & Krane, N.E.R. (2000). Four (or five)            Health, Washington, DC.
     sessions and a cloud of dust: Old assumptions        Lent, E.B. (1996). The person focus in career theory
     and new observations about career counseling.             and practice. In M.L. Savickas & W.B. Walsh
     In S.D. Brown & R.W. Lent (Eds.), Handbook of             (Eds.), Handbook of career counseling theory and
     counseling psychology (3rd ed., pp. 740–766).             practice (pp. 109–120). Palo Alto, CA: Davies-
     New York: Wiley.                                          Black.
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Locke, E.A., & Latham, G.P. (1990). Work motiva-               & S.H. Osipow (Eds.), Handbook of vocational psy-
     tion and satisfaction: Light at the end of the            chology: Applications (Vol. 2, pp. 141–180). Hills-
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Myers, I.B., McCaulley, M.H., Quenk, N.L., &              Slaney, R.B. (1978). Expressed and inventoried voca-
     Hammer, A.L. (1998). Myers-Briggs Type Indi-              tional interests: A comparison of instruments.
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     chologists Press.                                    Splete, H.H., & Hoppin, J.M. (2000). The emer-
Osipow, S.H., & Fitzgerald, L.F. (1996). Theories of           gence of career development facilitators. Ca-
     career development (4th ed.). Boston: Allyn &             reer Development Quarterly, 48, 340–347.
     Bacon.                                               Strong, E.K., Jr., Hansen, J.C., & Campbell, D.
Osipow, S.H., & Spokane, A.R. (1987). Occupational             (1994). Strong Interest Inventory. Palo Alto, CA:
     Stress Inventory manual, research version. Odessa,        Consulting Psychologists Press.
     FL: Psychological Assessment Resources.              Super, D., Thompson, A., & Lindeman, R. (1987).
Peterson, G.W. (1998). Using a vocational card sort            Manual for the Adult Career Concerns Inventory.
     as an assessment of occupational knowledge.               Palo Alto, CA: Consulting Psychologists
     Journal of Career Assessment, 6, 49–67.                   Press.
Rifkin, J. (1995). The end of work: The decline of the    Swanson, J.L., & Gore, P.A., Jr. (2000). Advances in
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     era. New York: Putnam.                                    Brown & R.W. Lent (Eds.), Handbook of coun-
Saks, A.M., & Ashforth, B.E. (1999). Effects of indi-          seling psychology (3rd ed., pp. 233 –269). New
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     335 –349.                                                 ment inventory: Users manual. Palo Alto, CA:
Saks, A.M., & Ashforth, B.E. (2000). Change in job             Consulting Psychologists Press.
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     Journal of Vocational Behavior, 56, 277–287.              theories of change and counseling. In S.D.
Sampson, J.P., Jr., & Lumsden, J.A. (2000). Ethical            Brown & R.W. Lent (Eds.), Handbook of counsel-
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     ment, 8, 21–35.                                      Watts, A.G. (2000). Career development and pub-
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     W.B. Walsh (Eds.), Handbook of career counseling     Wilson, W.J. (1996). When work disappears: The
     theory and practice (pp. 191–208). Palo Alto,             world of the new urban poor. New York: Al-
     CA: Davies-Black.                                         fred A. Knopf.
Savickas., M.L., & Spokane, A.R. (Eds.). (1999). Vo-      Zytowski, D. (1999). Kuder career search: Preview
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     psychology in industrial settings. In W.B. Walsh
                 EFFECTIVE COLLEGE
       4         COUNSELING


                 Neal E. Lipsitz



The primary goal of the college environment is         5. Minimal service. Minimal service provided
to promote learning and growth in students;               in all areas.
such personal change requires adjustment, and
the unique role of college counselors is to as-        More recently, however, Stone and Archer
sist students in dealing with the developmen-          (1990) emphasize the wide variation in col-
tal challenges that accompany personal                 lege counseling center design and function
growth. (Davis & Humphrey, 2000, p. 43)                even within each category. For example, varia-
                                                       tion occurs when centers of the same type op-
                                                       erate from different theoretical orientations
COLLEGE COUNSELING CENTER MISSIONS                     (e.g., psychodynamic vs. cognitive-behavioral)
AND FUNCTIONS                                          or with various service limits (e.g., short-term
                                                       vs. open-ended treatment modalities).
Addressing college counseling as a whole is                Because college counseling centers are not
difficult because just as every institution of         independent operations and serve only mem-
higher education is distinct, so is every col-         bers of a college community, their success in
lege counseling center. Counseling centers             meeting the needs of the community depends
differ according to the type of college in             on the degree to which they focus their activ-
which they reside (four-year/two-year, pub-            ities to mesh with the mission of the particu-
lic/private, large/small), the school’s mis-           lar college (Bishop, 1991). Clearly, centers
sion, and the resources available to them. Five        themselves also need an explicitly articulated
distinct types of centers were first identified        philosophy to function well. As these philoso-
by Whiteley, Mahaffey, and Geer (1987):                phies are set in the context of different insti-
                                                       tutional histories, mission statements, and
1. Macrocenter. Provides a wide range of clin-         service offerings, counseling centers neces-
   ical services such as personal and career           sarily differ significantly.
   counseling and testing, along with special              Finally, there is great variation in college
   functions including training and consulta-          students themselves. Some schools are more
   tion with limited advising.                         homogeneously populated (e.g., in terms of
2. Career planning and placement. Career-ori-          student ages and cultural backgrounds) and
   ented services with minimal counseling              others are more diverse. Because counseling
   and other functions.                                centers must meet the needs of the students
3. Counseling orientation. Similar to macro-           they serve, this too contributes to the differ-
   centers but with fewer career services.             ences among them.
4. General-level service. Wider functions in-              Regardless of this variability, essential roles
   cluding “dean of students”-type functions,          and functions for college counseling centers
   more services to a greater number of stu-           have been articulated and standardized. For
   dents than a conventional counseling center.        example, the Standards and Guidelines for

                                                  25
26       PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

Counseling Programs and Services by the                fairly homogeneous student populations now
Council for the Advancement of Standards in            find themselves challenged by the array of stu-
Higher Education (CAS, 1997) outline three             dent problems because students on every cam-
major functions for college counseling centers:        pus today show a wider range of previous life
developmental, remedial, and preventive. The           experiences, cultural backgrounds, socioeco-
developmental function is aimed at helping             nomic levels, interests, needs, developmental
students mature and succeed academically;              issues, and family structures. For example, a
the remedial function is designed to provide           31-year-old immigrant from Cambodia with a
professional clinical services to students with        full-time job, an extended family to help sup-
significant personal adjustment problems; and          port, and English as a second language is a
the preventive function focuses on neutraliz-          more likely member of the first-year class
ing environmental conditions that interfere            today than in the past. In addition, a greater
with student welfare. The Accreditation Stan-          proportion of students are likely to have expe-
dards for University and College Counseling            rienced mental health problems prior to col-
Centers by the International Association of            lege and to have sought professional help for
Counseling Services (IACS) (Kiracofe et al.,           those problems, including the use of medica-
1994) parallel those listed above. Stone and           tions (Altschuler, 2000). A recent study by the
Archer (1990), CAS (1997), and IACS (Kiracofe          World Health Organization (2000) that exam-
et al., 1994) also suggest more specific recom-        ined 30,000 people from seven countries con-
mendations, including consultation and out-            cluded that mental disorders are, in fact,
reach to a variety of groups in the campus             becoming more widespread across every age
community, staff development, crisis interven-         level. The Cooperative Institutional Research
tion, psychological and career testing, re-            Program survey (Sax, Astin, Korn, & Mahoney,
search, and evaluation of services.                    2000) found that among first-year students a
                                                       sense of being “frequently” overwhelmed has
                                                       grown steadily over the past 15 years (from
THE SCOPE AND INTENSITY OF STUDENT                     16% in 1985 to 31% in 1999).
NEEDS AND PROBLEMS                                        Whether psychopathology among college
                                                       students is truly more common has been ex-
College students typically bring four kinds of         tensively debated in the professional litera-
issues with them to the college experience             ture (Erickson Cornish, Riva, Henderson,
(Chandler & Gallagher, 1996):                          Kominars, & McIntosh, 2000; Gilbert, 1992;
                                                       O’Malley, Wheeler, Murphey, O’Connell, &
     Personal and social adjustment issues involving   Waldo, 1990; Pledge, Lapan, Heppner, Kiv-
     relationship difficulties, self-esteem, exis-     lighan, & Roehlke, 1998; Sharkin, 1997; Stone
     tential concerns, depression, sexual abuse        & Archer, 1990). R. Gallagher, Gill, and
     and harassment.                                   Sysko’s (2000) survey of counseling center di-
                                                       rectors revealed that 222 of 286 (77.6%) be-
     Academic and career concerns.
                                                       lieved that severe psychological problems
     Stress and psychosomatic symptoms, includ-        have increased in students over the past five
     ing anxiety.                                      years. On the other hand, Pledge, et al., (1998)
     Distressing symptoms related to substance         found that levels of student psychopathology
     abuse, sexual dysfunction, eating disor-          had not increased since the late 1980s in their
     ders, and unusual behavior.                       study of 2,000 college students between 1989
                                                       and 1995. These authors do suggest, however,
Generally, the most prevalent issues include           that the mental health issues college students
relationship difficulties, depression, anxiety,        present to college counselors have become
low self-esteem, stress, academic problems,            more consistently severe since the late 1980s.
and career concerns (Chandler & Gallagher,             Sharkin (1997) argued that increased pathol-
1996). Even college counseling centers with            ogy in college students is not supported by
                                                   4 • EFFECTIVE COLLEGE COUNSELING              27

empirical data but is actually a reflection of     identify a number of specific populations
the perception of college mental health clini-     with whom college counselors need to exhibit
cians. Cornish et al. (2000) concluded that it     competency:
was not the overall level of distress of stu-
dents that had increased, but a small increase        Multicultural/international students.
in the amount of extremely distressed stu-            Students with learning disabilities and at-
dents accounted for the perceptions of a wide-        tention deficits.
spread increase in psychopathology among
                                                      Older and nontraditional students, espe-
staff. Intuitively, this argument makes a lot of
                                                      cially women returning to education.
sense given the greater overall diversity of
college students today, their varied back-            Gay, lesbian, bisexual, and transgendered
grounds, and their potential for previous             students.
emotional health issues. A common challenge
for college counselors today, then, is the suc-       College counselors also need the ability to
cessful management of what is perceived to         be effective consultants to faculty, staff, par-
be, and may in fact be, a more demanding           ents, and the community, to provide meaning-
clinical caseload than in the past (Davis &        ful and effective outreach to the campus
Humphrey, 2000; Stone & Archer, 1990).             community, and to provide helpful career
   Whatever the true figure for its frequency,     counseling for students making the school-to-
effective treatment for students who present       work transition. The suggestion that college
more serious psychopathology is possible only      counseling centers “move beyond the therapy
if counseling center staff are adequately          office” is an often echoed theme (Davis &
trained to conduct thorough assessment, treat-     Humphrey, 2000; Stone & Archer, 1990; P. Gal-
ment planning, and direct intervention. Other-     lagher & Demos, 1983) because it is so crucial
wise, referral into the community, or even         to success in the competencies listed above.
refusal to treat, may be more in keeping with      When students see staff doing outreach, con-
the best interests of the client. Moreover, the    sultation, crisis intervention, training, and
need for psychiatric consultation remains high     the like, they tend to feel more comfortable
for both assessment of psychopathology and         about using the counseling center. This may
medication evaluation/monitoring.                  be especially true for students from diverse
                                                   cultural backgrounds, for whom trust may be
                                                   more easily established after a significant ex-
COMPETENCIES AND CHALLENGES                        posure on a more informal basis. In other
FACING COLLEGE COUNSELORS                          words, the major benefit from outreach is that
                                                   it provides multiple ports of entry to the
A related challenge is created by the breadth      counseling center.
of service expected of college counseling cen-
ter staff. The demands of clinical work are
strong, yet it would not be prudent for staff to   SPECIAL ETHICAL CHALLENGES IN
sit behind closed doors and wait for students      COLLEGE COUNSELING
to appear. In fact, a wide array of competen-
cies are required of counseling center staff.      The diverse roles of the college counselor and
Spooner, in Davis and Humphrey (2000), sug-        the closed nature of the community this pro-
gests that college counselors need to be pro-      fession services present several important
fessionally trained, multiculturally and           ethical challenges. Dual relationships are a
technologically competent, creative at prob-       distinct hazard, especially for counselors play-
lem solving, and capable of maintaining their      ing more than one role on campus (e.g., also
own physical, emotional, and spiritual equi-       teaching, advising a student organization, liv-
librium. Because of the increased diversity of     ing on campus). Counselors must be cognizant
the student body, Archer and Cooper (1998)         of their role in each setting and set appropriate
28     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

boundaries around their immediate interac-          most college students to resolve rather
tions with students. Maintaining confidential-      quickly the problems that brought them into
ity can be challenging when parents, deans,         counseling. Of course, some college students
professors, or concerned peers are looking for      are seen for longer-term counseling, and al-
information regarding a student they care           though that group generally uses up a rela-
about. If confidentiality is not adequately ex-     tively large portion of staff resources, they
plained to other campus professionals, coun-        also represent a relatively small portion of
selors can appear to be uncooperative and           each center’s clinical population.
difficult. “Duty to warn” can provide a poten-         Crisis intervention plays a central role in
tial safeguard for a third party when a client      the services rendered by college counseling
reveals that he or she is immanently going to       centers. When students are in the midst of
hurt the third party physically. Amada (1994)       emotional crises (e.g., psychotic breaks, sui-
speaks to the unique issues that arise when         cidal gestures or attempts, major grief reac-
college administrators refer disruptive stu-        tions, sexual assaults, substance abuse crises),
dents to the campus counseling center. At-          the campus community looks to professional
tempts to enact mandatory counseling by             staff from the counseling center to intervene.
deans, judicial affairs officers, alcohol educa-    Therefore, it is imperative that an effective cri-
tion personnel, and residence life staff, for ex-   sis response system be in place. This is often
ample, are probably best met with offers to         accomplished through a pager system enabling
provide “information sessions” to these stu-        at least one member of the counseling center
dents if they would like to find out what the       staff to be accessible at all times. Following a
counseling center has to offer them. The guid-      major catastrophe on campus (e.g., death of
ing principle is to protect the privacy and dig-    a student, multiple deaths in an accident, resi-
nity of the students as the highest priority but    dence hall fire), it is helpful to have a crisis-
also to recognize the rights and responsibili-      catastrophic emergency and postvention plan.
ties of faculty and administrators to the cam-      Counseling center staff should be prepared to
pus community.                                      play a central role in the response to such
                                                    events. Of the 311 counseling center directors
                                                    surveyed by P. Gallagher et al. (1999), 214
INNOVATIONS AND EMERGING ISSUES                     (70.4%) had a procedure in place for dealing
                                                    with such incidents. A common model of re-
Brief therapy is a mode that has shown some         sponse to traumatic incidents that can be
efficacy in helping college counselors deal         adapted for use on a college campus is the Crit-
with the demand for services (Archer &              ical Incident Stress Management model
Cooper, 1998). Even clients with more serious       (Mitchell & Everly, 1993).
presenting problems appear to benefit from             College counseling centers have long been
this approach, at least as a way to become pre-     committed to viewing student issues in the
pared for more extensive therapy. And brief         context of the life transitions students are ex-
intermittent therapy is a natural approach for      periencing. This developmental perspective
college students, as they are in a position to      assumes that students approach their prob-
work on various issues in short order as they       lems in a manner that is consistent with their
progress through their college years. In fact,      level of development. Our job as college coun-
the National Survey of Counseling Center Di-        selors, then, is to help students mature as
rectors (P. Gallagher, Gill, Goldstrohm &           they progress through the transitional issues
Sysko, 1999) indicated that the average num-        they are facing. This is a health-oriented per-
ber of sessions per client was five, whether or     spective rather than a psychopathological
not session limits were in place. As a fairly       one. For example, first-year college students
standard finding across college counseling          are generally dealing with issues related to
centers nationwide, this statistic illustrates      leaving home and establishing a life indepen-
the developmental readiness that enables            dent of their families. Sophomores, having
                                                     4 • EFFECTIVE COLLEGE COUNSELING              29

left the novelty of first year behind, can feel      (POAMS) (Kopta & Lowry, 2000). As this
lost, not knowing what direction to choose ac-       practice continues, along with the need to
ademically and/or relationally as they work          conduct needs assessments of students, per-
to define themselves intrapersonally. Juniors        haps increased attention to accountability is-
often begin to feel the press of their adult         sues will translate into informative research
lives after college starting to make an impact       in this area.
and deal with issues of commitment to poten-            Counseling centers will also need to assess
tial career paths as well as relationships. Se-      the effectiveness of the many innovations that
niors, for whom graduation is in sight, often        seem to be developing into standard practice.
deal with issues related to leaving their col-       For example, national mental health screening
lege lives behind, moving into their career,         days are more common on college campuses
and facing financial independence.                   every year, and the breadth of screenings is in-
   Counseling centers have long been encour-         creasing. Many campuses now offer depres-
aged to engage in research for accountability        sion, anxiety, alcohol, and eating disorders
purposes (Stone & Archer, 1990). Bishop (1991)       screening days on a yearly basis. Currently, lit-
suggested that “successful efforts at strategic      tle independent research on the impact of
planning will . . . require the systematic collec-   these events has been conducted.
tion of data about what a counseling center             Partnerships between college counseling
staff actually does and how well it performs its     centers and community agencies account for
functions” (p. 408). He goes on to suggest that      another innovation. To provide adequate ser-
maintaining a database for self-study can help       vices to students presenting with substance
clarify problem areas so they can then be recti-     abuse, eating disorders, or sexual assault is-
fied. At a more basic level, data are necessary      sues, ancillary services in the community are
so that counseling centers can describe their        often warranted. Such services may include:
activities to the decision makers at their insti-
tutions as well as understand student culture        • A substance abuse center with detoxifica-
and the related demand on counseling services          tion capabilities for substance abusing
(Bishop, 1995).                                        students.
   In their follow-up to Stone and Archer’s          • Nutritional counseling, medical monitor-
article on the challenges that college and uni-        ing, and a support group for eating disor-
versity counseling centers faced in the 1990s,         dered students.
Guinee and Ness (2000) indicated that coun-          • Medical and legal resources for student
seling centers are paying increased attention          survivors of sexual assault through con-
to accountability issues. They also report that        tacts with the local hospital, the rape crisis
centers can no longer compete for tight re-            center, or the sexual assault unit of the
sources simply through data on students                local police department.
served or evidence of high levels of client sat-
isfaction. These authors suggest that centers           Still another innovation is related to
must assess the efficacy of their practices,         increased accessibility of mental health
study the demographics of their clients, and         providers on campus. Recognizing that stu-
chart the actual severity of problem presenta-       dents do not function on an ordinary, business
tions in counseling center clients. However,         hours schedule, counseling centers are having
Guinee and Ness also point out that little           success meeting student needs by expanding
progress has actually been made in conduct-          hours of operation. Accessibility is further ex-
ing systematic research in these areas over          tended with a 24-hour, seven days/week emer-
the past 15 years. More centers are beginning        gency coverage system with a pager service
to use outcome questionnaires such as the            and counseling center Web site with links that
Outcome Questionnaire-45.2 (OQ-45.2) (Lam-           can provide psychoeducation to an unlimited
bert et al., 1996) or the Psychotherapy Out-         number of students anytime anyone is inter-
come Assessment and Monitoring System                ested. Examples of Web sites that include
30     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

relevant information about college student          Association (ACCA). The Journal of College
mental health issues are:                           Counseling is published by ACCA. The Journal of
                                                    American College Health is published by the
• Dr. Bob’s Mental Health Links at the Uni-         ACHA. Other journals related to the work of
  versity of Chicago (www.uhs.bsd.uchicago          college counselors include Journal of College Stu-
  .edu/∼bhsiung/mental.html).                       dent Development, Journal of College Student Psy-
• Counseling Center Village at the University       chotherapy, and Journal of College Mental Health.
  of Buffalo, with links to university and col-
  lege counseling center Web sites world-
  wide, self-help Web pages, and a virtual          SUMMARY
  pamphlet collection (www.ub-counseling
  .buffalo.edu/ccv.html).                           These are challenging times for college and
• Self-help brochures at the University of          university counseling centers. The current
  Illinois at Urbana-Champaign (www.couns           trend demands that competent and profes-
  .uiuc.edu/brochure.htm).                          sional services be rendered on a wide range of
                                                    mental health issues, for a more clinically de-
   Clearly, computer technology accounts for        manding population, in ways that effectively
a large proportion of the recent innovations in     reach a diverse group of students with in-
college counseling. Computer list-serves,           creased accountability and fewer resources.
such as the directors’ list-serve of the Associ-    Fortunately, standards, guidelines, and a
ation of University and College Counseling          wide variety of tools exist to help us with this
Center Directors (AUCCCD), are an example           task. Many of these resources have been ad-
of computer-based innovations. Davis and            dressed in this chapter. Standards such as
Humphrey (2000) point out various forms of          those published by CAS and IACS help us to
high-technology communications that have            define our roles and functions clinically and
the potential to extend counseling service de-      administratively. Competency requirements,
livery itself if counselors adopt them (e.g.,       professional ethics, and common practices
chat rooms, bulletin boards, Web sites, e-mail,     guide us toward the appropriate application
Web counseling, and simultaneous audio and          of our trade. Tools made available through ad-
video transmission).                                ministrative innovation, accountability mea-
                                                    sures, professional affiliations, and improved
                                                    communication and computer technology
RESOURCES FOR COLLEGE COUNSELORS                    help us to serve our campus communities
                                                    more effectively and efficiently. With suffi-
How can college counselors keep up with de-         cient awareness of these resources, and by
velopments in the field of college mental           working cooperatively, we can meet the chal-
health? As is true with all professions, the pro-   lenges of today and realize our goals for
fessional associations and related journals are     tomorrow.
excellent sources of information. Organiza-
tions worth joining include the American Psy-       References
chological Association (APA), the American
Counseling Association (ACA), and the Amer-         Altschuler, G.C. (2000, August 6). Adapting to col-
ican College Health Association (ACHA). Of               lege life in an era of heightened stress. New
                                                         York Times, pp. 12, 16.
specific interest in APA is Division 17, which
                                                    Amada, G. (1994). Coping with the disruptive college
is devoted to the field of Counseling Psychol-
                                                         student: A practical model. Asheville, NC: Col-
ogy, clearly the most directly related profes-           lege Administration Publications.
sional training program for doctoral-level          Archer, J., & Cooper, S. (1998). Counseling and mental
college counselors. The Counseling Psychologist          health services on campus: A handbook of contem-
is published by Division 17 of APA. Affiliated           porary practices and challenges. San Francisco:
with ACA is the American College Counseling              Jossey-Bass.
                                                         4 • EFFECTIVE COLLEGE COUNSELING                     31

Bishop, J.B. (1991). Managing demands on counsel-        Kopta, S.M., & Lowry, J.L. (2000). The Psychotherapy
     ing services: A process of change (A response            Outcome Assessment and Monitoring System:
     to Dworkin and Lyddon). Journal of Counseling            College counseling center version. Unpublished
     and Development, 69, 408– 410.                           manuscript.
Bishop, J.B. (1995). Emerging administrative strate-     Lambert, M.J., Hansen, N.B., Umphress, V., Lunnen,
     gies for college and university counseling               K., Okiishi, H., Burlingame, G.M., Heufner,
     centers. Journal of Counseling and Development,          J.C., & Reisinger, C.R. (1996). Administration
     74, 33 –38.                                              and Scoring manual for the Outcome Questionnaire
Chandler, L.A., & Gallagher, R.P. (1996). Develop-            (OQ-45.2). Wilmington, DE: American Profes-
     ing a taxonomy for problems seen at a univer-            sional Credentialing Services LLC.
     sity counseling center. Measurement and             Mitchell, J.T., & Everly, G.S. (1993). Critical incident
     Evaluation in Counseling and Development, 29,            stress debriefing (CISD): An operations manual for
     4 –12.                                                   the prevention of traumatic stress among emer-
Council for the Advancement of Standards in                   gency services and disaster workers. Elliott City,
     Higher Education. (1997). The CAS book of pro-           MD: Chevron Corporation.
     fessional standards for higher education. Wash-     O’Malley, K., Wheeler, I., Murphey, J., O’Connell,
     ington, DC: Author.                                      J., & Waldo, M. (1990). Changes in levels of
Davis, D.C., & Humphrey, K.M. (Eds.). (2000). Col-            psychopathology being treated at college and
     lege counseling: Issues and strategies for a new         university counseling centers. Journal of Col-
     millennium. Alexandria, VA: American Coun-               lege Student Development, 31, 464 – 465.
     seling Association.                                 Pledge, D.S., Lapan, R.T., Heppner, P.P., Kivlighan,
Erickson Cornish, J.A., Riva, M.T., Henderson,                D., & Roehlke, H.J. (1998). Stability and sever-
     M.C., Kominars, K.D., & McIntosh, S. (2000).             ity of presenting problems at a university
     Perceived distress in university counseling              counseling center: A 6-year analysis. Profes-
     center clients across a six-year period. Journal         sional Psychology: Research and Practice, 29,
     of College Student Development, 41, 104 –109.            386 –389.
Gallagher, P.J., & Demos, G.D. (1983). Handbook of       Sax, L.J., Astin, A.W., Korn, W.S., & Mahoney, K.M.
     counseling in higher education. New York:                (1999). The American freshman: National norms
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     Sysko, H.B. (1999). National survey of counseling   Sharkin, B.S. (1997). Increasing severity of present-
     center directors. Alexandria, VA: International          ing problems in college counseling centers: A
     Association of Counseling Services.                      closer look. Journal of Counseling and Develop-
Gallagher, R.P., Gill, A.M., & Sysko, H.B. (2000).            ment, 75, 275 –281.
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     Alexandria, VA: International Association of             university counseling centers in the 1990’s:
     Counseling Services.                                     Challenges and limits. The Counseling Psychol-
Guinee, J.P., & Ness, M.E. (2000). Counseling cen-            ogist, 18, 539–607.
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     and Development, 73, 38– 43.
                 DIVORCE
       5         COUNSELING


                 Katherine M. Kitzmann and Noni K. Gaylord




Divorce rates in the United States reached              from nondivorced families, children from di-
historically high levels in the 1980s, making           vorced families are at higher risk for academic
divorce a normative experience in American              problems, externalizing and internalizing
society (National Center for Health Statistics,         disorders, low social competence, low self-
1995). Although the divorce rate showed a               esteem, and problems in close relationships
downward trend in the 1990s, at least 50% of            (Amato & Keith, 1991b). However, it should be
recent marriages are expected to end in di-             noted that although the divorce transition is
vorce (Cherlin, 1992), and about 60% of cur-            associated with significant distress for many,
rent divorces involve children (National                the normative outcome is resilience, with
Center for Health Statistics, 1995). The transi-        most children and adults eventually showing
tion to divorce is often a significant stressor         good psychological adjustment to the stressor
for both adults and children. Members of di-            of divorce (Emery, 1999).
vorced families are two to three times as                  It is probably most helpful to think of di-
likely to receive psychological treatment com-          vorce as a process of life transitions rather
pared to members of married families                    than as a single event. Longitudinal research
(Howard et al., 1996). Family members seek              shows that much of the distress observed
help both for dealing with psychological dis-           after divorce actually begins prior to divorce
orders, which are more common among chil-               and can be attributed to the strains of un-
dren and parents in divorced families, but              happy marital and family relationships (Cher-
also for help in dealing with subclinical prob-         lin et al., 1991). The first two years following
lems, such as painful feelings, unhappy mem-            divorce are associated with significant dis-
ories, and ongoing distress associated with             tress and disruption in family life. By two
the family disruption (Emery, 1999).                    years after divorce, however, most adults and
   Research shows that adults and children              children are adapting reasonably well (Het-
show a range of outcomes associated with the            herington, 1989). For both men and women,
divorce transition. Among adults, anxiety, de-          psychological well-being increases after the
pression, alcohol abuse, loneliness, impulsiv-          formation of a new mutually caring, intimate
ity, and emotional lability may emerge or               relationship, such as a successful remarriage
increase in the aftermath of divorce (Bloom,            (Hetherington, 1993). However, remarriage
Asher, & White, 1978; Hetherington, 1993).              can present its own set of stressors when
Separated and divorced adults, especially               children are involved. The fact that divorce
men, are also at increased risk for compro-             rates are even higher in remarriages than in
mised immune system functioning and physi-              first marriages means that many adults and
cal illness (Burman & Margolin, 1992; Dura &            children actually undergo multiple divorce-
Kiecolt-Glaser, 1991). Compared to children             related transitions (Cherlin, 1992).

                                                   32
                                                              5 • DIVORCE COUNSELING            33

COUNSELING ADULTS DURING THE                      solution-focused techniques for adults dealing
DIVORCE TRANSITION                                with divorce-related distress.
                                                     Many divorcing adults seek help through
Men and women going through divorce seek          support groups and group-based intervention
therapy at much higher rates than do married      programs. These programs typically involve 6
adults (Howard et al., 1996). These adults        to 24 hours of group meetings and address
show a wide range of responses to divorce, in-    topics such as finding a new support system,
cluding painful emotions of anger and sad-        feelings of isolation and diminished self-
ness, feelings of guilt and remorse, and relief   esteem, running a household alone, financial
and excitement about the termination of a dif-    planning, and dating (Lee, Picard, & Blain,
ficult marriage. Counseling can provide a safe    1994). These programs appear to be helpful in
place to express these feelings and to experi-    decreasing symptoms of depression and over-
ence grief related to the multiple losses asso-   all distress, with average improvement levels
ciated with the dissolution of a marriage.        comparable to typical psychotherapy out-
These include loss of a partner, loss of the      comes (Lee et al., 1994). Programs that have
dream of being happily married, and loss of       proven effective in improving participants’
roles, including one’s role as spouse and as a    psychological adjustment and parenting skills
member of the spouse’s extended family. For       include the Colorado Separation and Divorce
many adults, divorce also involves significant    Project (Hodges & Bloom, 1986), the Divorce
changes in parent-child relationships and di-     Adjustment Project (Stolberg & Cullen, 1983),
minished contact with children, an especially     the Children of Divorce Parenting Interven-
important stressor for the noncustodial par-      tion (Wolchik et al., 1993), and the Parenting
ent (Kitson, 1992). In some cases, parents who    through Change program (Forgatch & De-
have difficulty accepting the reality of di-      Garmo, 1999).
vorce will engage in drawn-out litigation as a       Many divorcing adults participate in short-
way to maintain connection with the spouse        term workshops designed to improve family
(Emery, 1994). Counseling can assist these in-    functioning during the divorce transition. Al-
dividuals to find more effective ways to deal     though parents report high consumer satis-
with issues of loss and acceptance.               faction with these programs, research using
   Counselors can provide an important ele-       control groups suggests little objective benefit
ment of social support during the divorce         either in terms of parenting or child function-
transition and can help the divorced adult        ing (Emery, Kitzmann, & Waldron, 1999). The
problem-solve about ways to make use of other     strong interest in short-term programs, both
forms of support. Divorced adults commonly        on the part of community members and the
report social isolation and loneliness; in one    court system, provides an opportunity for re-
study, 30% of divorced adults still experienced   searchers to evaluate what works and what
severe loneliness even 16 months after the di-    does not (Emery et al., 1999).
vorce (Spanier & Thompson, 1983). Counsel-
ing can also address the multiple life changes
that accompany divorce, which might include       COUNSELING CHILDREN AFFECTED
moving, establishing an independent house-        BY DIVORCE
hold, and finding employment. These stres-
sors are especially relevant for women, as the    The transition to divorce is one that affects all
economic impact of divorce is significantly       members of the family, and many children are
more negative for women than for men              referred for counseling during this difficult
(McLanahan & Booth, 1989). Even small             period. Children often have to cope simulta-
changes in coping strategies can be helpful in    neously with painful emotions about their
the face of these many stressors. One helpful     parents’ divorce and with other transitions
resource for clients is Weiner-Davis’s (1992)     such as moving, changing schools, and mak-
book Divorce Busting, which describes brief,      ing new friends. The child’s ability to cope
34     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

with these stressors can be compromised by          love for and anger toward both parents, dis-
parents’ expression of hostility toward one         cuss misconceptions about the cause of divorce
another, ongoing interparental conflict sur-        and who is to blame, and then begin to learn
rounding visitation or joint custody, or de-        skills to overcome divorce-related fears and to
creased or unpredictable contact with the           cope with the divorce transition. Play therapy
noncustodial parent. Many children show             is commonly used with younger children,
problems during this transition, the most           whereas older children and adolescents are
common being aggression and conduct prob-           more able to talk openly about their experi-
lems (Amato & Keith, 1991b). Boys and girls         ences related to their parents’ divorce. Waller-
appear to be equally affected, but may be dif-      stein (1989) has noted that regardless of the
ferentially impacted by a parent’s subsequent       child’s age, adaptation to divorce involves sev-
remarriage. For example, research in mother-        eral psychological tasks. First, children must
custody families has shown that boys’ prob-         acknowledge the reality of the marital rupture
lems tend to decrease with the addition of a        and disengage from parental conflict and dis-
stepfather, whereas this transition can entail      tress. With time, children resume a routine
new stressors for girls, who may have become        and customary activities and experience some
closer to their mothers after the divorce (Het-     resolution of their feelings of loss, self-blame,
herington, Bridges, & Insabella, 1998).             and anger. Finally, children must accept the
   Developmental factors are critical in the        permanence of the divorce and achieve realis-
discussion of counseling for children of di-        tic hopes about relationships.
vorce. Most children are younger than 6 when            Counselors can play an important role in
their parents divorce (Emery, 1999), and a          encouraging parents to talk honestly with
great deal of the clinical literature focuses on    their children about the divorce at a level ap-
the needs of these very young children. Among       propriate for the child’s age. Parents can as-
preschoolers from divorced homes, conduct           sure their children that they are not to blame
problems are most prevalent (Amato & Keith,         and are not responsible for helping the par-
1991b), and preschoolers also show significant      ents to get along. At the same time, parents
confusion about being to blame for the divorce      should be encouraged not to discuss with
and about whether divorce means that a parent       their children topics that are more appropri-
no longer loves them (Knoff & Bishop, 1997).        ately discussed with other adults, such as
In general, however, children in elementary         feelings of hostility toward the ex-spouse,
and high school show more problems after di-        conflict over visitation or joint custody
vorce than do preschoolers or college students      arrangements, and insecurities about fi-
(Amato & Keith, 1991b). School-age children         nances. Parents can be helped to make the
are more likely than younger children to try to     child’s life as stable and consistent as possi-
mediate their parents’ conflict, and although       ble, both within the custodial household and
they may be better able to understand that di-      between households in cases of frequent visi-
vorce is not their fault, they may still feel re-   tation or joint custody. Books that may be
sponsible for fixing the problem (Knoff &           helpful to parents include Mom’s House, Dad’s
Bishop, 1997). For adolescents, parental di-        House: A Complete Guide for Parents Who Are
vorce may highlight struggles with the transi-      Separated, Divorced, or Remarried (Ricci, 1997),
tion to young adulthood (Hodges, 1991). As          How It Feels When Parents Divorce (Krementz,
adults, children of divorce are at higher risk      1999), Don’t Divorce Us! Kids’ Advice to Divorc-
for depression and life dissatisfaction (Amato      ing Parents (Sommers-Flanagan, Elander, &
& Keith, 1991a) and are much more likely than       Sommers-Flanagan, 1999), and Dinosaurs Di-
other adults to divorce themselves (Amato,          vorce: A Guide for Changing Families (Brown &
1996).                                              Krasny, 1999).
   Individual counseling can provide a safe             In addition to individual counseling,
environment for the child to grieve the multi-      school-based group therapy programs are a
ple losses inherent to divorce, express both        common intervention for children of divorce.
                                                                5 • DIVORCE COUNSELING           35

Groups typically meet for 6 to 16 weeks and         holds, and can help maintain and strengthen
are designed to lessen children’s isolation and     children’s relationships with both parents.
loneliness, foster support and trust, and clar-     Family therapy may also be helpful during the
ify misconceptions about divorce. As a whole,       transition to remarriage and stepparenting, a
these groups show considerably lower effec-         period in which family roles and rules can be
tiveness than psychotherapy in general (Lee         in flux (Crosbie-Burnett & Ahrons, 1985;
et al., 1994). Two exceptions are the Children      Visher & Visher, 1988).
of Divorce Intervention Project, a 12-week in-
tervention for children from kindergarten
through sixth grade (Pedro-Carroll & Cowen,         SUMMARY
1985), and the Divorce Adjustment Project, a
12- to 14-week program for children age 7 to        Members of divorced families are two to
13 (Stolberg & Mahler, 1994).                       three times as likely as members of married
                                                    families to receive psychological treatment
                                                    (Howard et al., 1996). Common interventions
COUNSELING COUPLES AND FAMILIES                     during the transition to divorce include indi-
AFFECTED BY DIVORCE                                 vidual therapy for adults and for children,
                                                    support groups for adults, school-based inter-
Although most divorce-related counseling            vention programs for children, mediation for
targets individual adjustment, interventions        couples, and family therapy.
with two or more family members can also be             Several points should be highlighted. First,
helpful during the transition to divorce. Child     little research has been conducted on the ef-
custody mediation is an increasingly common         fectiveness of individual counseling for adults
alternative to litigation that many hope can        or children affected by divorce, or of family
act as a preventive intervention by improving       therapy for divorced and remarried families.
coparenting and minimizing children’s expo-         Whereas group-based interventions for di-
sure to poorly resolved conflict (Emery &           vorced adults have been found to be about as
Wyer, 1987). Mediation is associated with           effective as individual therapy for improving
faster resolution and fewer court hearings          psychological adjustment (Lee et al., 1994),
(Emery, 1994), higher participant satisfaction      most “weekend workshop” programs have not
(Emery, Matthews, & Kitzmann, 1994), and            proven effective. With some high-quality
increased compliance with child support             exceptions, most school-based programs for
agreements as well as greater involvement by        children also show limited effectiveness. Me-
noncustodial fathers in their children’s lives      diation, although beneficial in several re-
(Dillon & Emery, 1996). However, mediation          spects, is not associated with significant
has not been shown to be associated with any        improvement in family members’ mental
mental health benefits, either for parents or       health and is not a substitute for traditional
children (Emery et al., 1994; Kitzmann &            forms of intervention.
Emery, 1994).                                           Second, it is most helpful to think of di-
   Family therapy is another resource that          vorce not as a single event, but as a process of
may be helpful during divorce-related transi-       transitions. Longitudinal research suggests
tions. Although parents may be divorced and         that many of the problems thought to be
living apart, they may still meet regularly with    caused by divorce are actually present well
their children in family therapy, especially in     before the divorce occurs. After divorce, the
cases of joint physical custody or frequent visi-   first two years are the most stressful, but most
tation (Isaacs, Montalvo, & Abelsohn, 1986).        adults and children show great improvement
Family therapy can help parents learn to shel-      by two years. Several years after the divorce,
ter their children from poorly resolved inter-      however, many divorced adults remarry, a
parental conflict and to provide consistent         transition that can bring both benefits and
expectations and rewards in the two house-          additional stressors. Because the divorce rate
36     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

is even higher in second marriages than in              Cherlin, A. (1992). Marriage, divorce, remarriage.
first marriages, many adults and children are                Cambridge, MA: Harvard University Press.
actually going through multiple transitions             Cherlin, A., Furstenberg, F.F., Chase-Lansdale,
over the course of several years.                            P.L., Kiernan, K.E., Robins, P.K., Morrison,
   Finally, although the risk for psychological              D.R., & Teitler, J.O. (1991). Longitudinal stud-
                                                             ies of effects of divorce in children in Great
problems and involvement in therapy are both
                                                             Britain and the United States. Science, 252,
significantly higher in divorced families,
                                                             1386 –1389.
most adults and children affected by divorce            Crosbie-Burnett, M., & Ahrons, C.R. (1985). From
can be described as resilient, as most do not                divorce to remarriage: Implications for ther-
show mental health problems and most do                      apy with families in transition. Journal of Psy-
not seek therapy (Emery et al., 1999). This is               chotherapy and the Family, 1, 121–137.
not to say that divorce has no impact, as many          Dillon, P., & Emery, R.E. (1996). Divorce mediation
people affected by divorce report significant                and resolution of child custody disputes: Long-
painful emotions, even years afterwards                      term effects. American Journal of Orthopsychia-
(Laumann-Billings & Emery, 2000). However,                   try, 66, 131–140.
it would be a mistake to conclude that divorce          Dura, J.R., & Kiecolt-Glaser, J.K. (1991). Family
                                                             transitions, stress, and health. In P.A. Cowan
by itself is the sole cause of the adjustment
                                                             & E.M. Hetherington (Eds.), Family transitions
problems seen in adults and children from
                                                             (pp. 59–76). Hillsdale, NJ: Erlbaum.
divorced families, as members of nondivorced            Emery, R.E. (1994). Renegotiating family relationships:
high-conflict families have psychological                    Divorce, child custody, and mediation. New York:
problems comparable to those seen in families                Guilford Press.
of divorce (Amato,1999). It is most helpful to          Emery, R.E. (1999). Marriage, divorce, and children’s
view clients’ problems as a response to multi-               adjustment (2nd ed.). Newbury Park, CA:
ple stressors, including marital conflict and                Sage.
problematic family relationships.                       Emery, R.E., Kitzmann, K.M., & Waldron, M. (1999).
                                                             Psychological interventions for separated and
                                                             divorced families. In E.M. Hetherington (Ed.),
                                                             Coping with divorce, single parenting, and remar-
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                                                                       5 • DIVORCE COUNSELING                    37

Hodges, W., & Bloom, B. (1986). Preventive inter-             investigation of the efficacy of a school-based
     vention program for newly separated adults:              prevention program. Journal of Consulting and
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     3, 35 – 49.                                         Ricci, I. (1997). Mom’s house, dad’s house: A complete
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Pedro-Carroll, J.L., & Cowen, E.L. (1985). The
     Children Cope with Divorce program: An
                 DEATH AND
       6         BEREAVEMENT


                 Stephen J. Freeman




Those in the counseling profession often have             attachment behaviors that were effective in
as their guiding light, and rightly so, the idea          maintaining the attachment bond while the
that counseling and therapy should instill                deceased was alive are no longer working.
hope. In light of this view, there may be a hes-          The person begins to wonder if any part of
itancy to venture into the perceived hope-                prior life is salvageable. This can create de-
defeating realm of death and bereavement.                 spair. The self without the deceased person
The question arises, Why study such topics?               must be reevaluated and redefined, requir-
The answer is simple: Death is a natural part             ing full acceptance of the loss.
of life and bereavement is an inescapable con-             Phase IV: Phase of greater or lesser degree
comitant part of that life and of our natural             of reorganization. Now that the bereaved
inclination to relate to and bond with others.            individual has come to a realization that
   A death loss is a disruption in the attach-            life must go on, various changes may begin
ment bond a person has with a significant                 to take place. Thoughts of the deceased
other in his or her environment. As such, the             begin to take a different place in the be-
system must reorganize to a different level.              reaved’s life. Social relationships and re-
The self is a system whose task is to regulate            sponsibilities may also be changing to
behavior designed to maintain contact with a              accommodate a world without the person
significant other. The goal of the system is to           who was lost. (p. 85)
maintain comfort and security through con-
nectedness. This reorganization process gen-
erally follows four phases (Bowlby, 1980):
                                                        THE GRIEF EXPERIENCE

  Phase I: Phase of numbing. This phase is
                                                        In addition to Bowlby’s phases, Westberg
  characterized by an initial disbelief that
                                                        (1962) lists ten fairly common stages for peo-
  the death has actually occurred and usu-
                                                        ple in grief. These are described below. It
  ally lasts from a few hours to a week and
                                                        should be understood, however, that grief is
  may be interrupted by outbursts of ex-
                                                        fluid and most people do not begin with stage
  treme emotion.
                                                        1 and proceed in an orderly fashion to stage
  Phase II: Phase of yearning and searching.            10. There is a great deal of movement among
  Survivors may be restless, preoccupied                and within the stages, and often, bereaved in-
  with thoughts of the deceased, and prone to           dividuals will comment that after a week or
  initially interpret events (phone ringing,            two of “progress,” they have reverted back to
  door opening) as coming from the deceased             the beginning. It is important to remember
  person.                                               that grief contains the emotional illusion of
  Phase III: Phase of disorganization and               regression when, in fact, movement is always
  despair. It will become apparent that                 forward. At worst, one is merely standing

                                                   38
                                                            6 • DEATH AND BEREAVEMENT               39

still. As long as the grieving process is not di-        How can he or she be at peace knowing I am
luted or interrupted, there is progress:                 suffering so much?” There is also the fear
                                                         that the anger being felt toward God will
 1. Shock. The shock of death is to be ex-               bring about punishment in the form of ad-
    pected even after a long illness and                 ditional losses. Many experience deep anxi-
    months of anticipatory grief. People often           ety over the possibilities of forgetting their
    describe the first few weeks of grief as             loved one and will express concern that
    having been on autopilot. There is little            they can no longer recall how the person
    actual memory of specific details, merely            smiled or how his or her voice sounded.
    the knowledge that one did what had to          6.   Hostility. Anger usually surfaces in the
    be done. Shock usually wears off after               sixth or eighth week after death. This rage
    five or six weeks, but may last much                 is sometimes random, sometimes specific.
    longer, depending on the person’s skill at           God, medical professionals, clergy, and the
    self-protection from painful feelings and            deceased are frequent targets. Usually, the
    the significance of the relationship.                individual is confused by the intensity of
 2. Emotional Release. It is not uncommon to             the anger, seeing it as inappropriate but
    see intense emotional release at the time of         feeling unable to defuse it.
    the death, and then have it seem to dry up      7.   Guilt. Guilt is sometimes real, often
    for a number of weeks. When the shock fi-            imaginary or exaggerated, but should al-
    nally dissipates, the bereaved will often            ways be taken with great seriousness.
    feel strong emotions such as anger, fear, re-        Death amplifies whatever problems ex-
    morse, and extreme loneliness. Lives are             isted in the relationship, and even minor
    reviewed during this period, and people              life issues that had been virtually ignored
    are amazed to discover the degree of de-             are now insurmountable obstacles for the
    pendence they felt for the person who                survivor. The “shoulds” seem to rule the
    died. This can lead to loss of self-esteem           world of the bereaved: “I should have
    and feelings of inadequacy.                          done this. I should not have done that.”
 3. Depression. Depression takes the emo-                Rational explanations may soothe for a
    tions mentioned above and intensifies                time, but usually the guilt will return
    them, adding feelings of helplessness and            until resolution is achieved. No one can
    hopelessness. The bereaved will complain             punish us better that we can punish our-
    of not feeling their loved one close to              selves, and the instrument is guilt.
    them anymore, of wanting to be with him         8.   Fear. Fear wears many faces with the be-
    or her. There are fears of suicide from              reaved. There may be a fear of sleeping in
    friends and family, but the bereaved will            the same bed or room. There may be a fear
    usually express it as “I won’t do anything           of leaving the house or of staying in it. Peo-
    to myself, but if death comes for me                 ple are afraid of the aloneness that comes
    tonight, I won’t fight it.”                          after a death, and they are also afraid of
 4. Physical Symptoms of Distress. This is a             beginning new relationships, however pla-
    very common phenomenon, especially in                tonic these may be. There is a fear of never
    children. If the deceased died of a heart            knowing joy again or not being able to
    attack, the survivor(s) may experience               laugh without guilt. The act of living be-
    tightness in the chest, pain radiating to            comes fearful for the person who feels so
    the jaw and down the left arm, and other             lost without his or her loved one, and each
    symptoms associated with a heart attack.             day is a burden to be endured.
 5. Anxiety. The bereaved experience vivid          9.   Healing through Memories. The bereaved
    dreams, waking and sleeping, in which                move back and forth between good memo-
    they see or hear their loved one. There is           ries and bad. At times, it seems that there
    also spiritual anxiety, expressed as “Where          is a need for self-punishment, and so all
    is my loved one now? Is he or she happy?             the negative aspects of the relationship are
40     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

    resurrected and relived. The happier mo-       reality that the person has died and will not be
    ments often seem too painful, and it may       coming back. Questions to ask yourself as a
    take many months before these can be           counselor working with the bereaved:
    faced, but there is healing in remember-
    ing. As the memories become less painful,         Where is the person in terms of con-
    there is an ability to begin to face the          fronting the reality that his or her loved
    world once again.                                 one has died?
10. Acceptance. There is a difference between
                                                      Do I need to respect the person’s need to
    accepting the reality of death (thereby let-
                                                      avoid the full reality of the loss for a pe-
    ting go) and forgetting the person who has
                                                      riod of time while attempting to help him
    died. As with the healing of any serious
                                                      or her cautiously confront this new reality?
    wound, there will always be a scar to re-
    mind one of the injury. With time will            Is the person using unhealthy defense
    come a lessening of the pain, until finally       mechanisms such as overuse of alcohol,
    the injury can be touched, remembered,            overeating, the traveling cure, or similar
    and accepted as a new part of the life being      behaviors?
    lived. This acceptance may take two years
    or more to achieve, depending on the              The second task of mourning is to tolerate
    depth of emotional investment one made         the emotional suffering that is inherent in the
    in the relationship with the deceased.         grief while nurturing oneself both physically
                                                   and emotionally (Parks & Weiss, 1983;
   Within these phases and stages, there is a      Shuchter & Zisook, 1990; Worden, 1991). The
continuum of behaviors ranging from normal         thoughts and feelings (pain of grief) resulting
and healthy to dysfunctional for the person        from this encounter with death must be ab-
who is grieving. Westberg’s (1962) theory          sorbed. If avoided or denied, the movement
suggests that the patterns of loss following a     toward resolution is inhibited. Questions to
death are similar ( but not identical in dura-     ask yourself as a counselor working with the
tion or intensity) regardless of age, gender, or   bereaved:
relationship to the deceased.
                                                      Has the person allowed himself or herself
                                                      to experience the pain of grief? If so, with
THE NORMAL EXPERIENCE OF GRIEF:                       whom has he or she shared their grief?
FACILITATING GRIEF COUNSELING                         Was the person provided with a sense of
                                                      feeling understood in the expression of his
A helpful concept for both the mourner and            or her grief?
the caregiver is the tasks of mourning. The
mourner’s awareness of these needs or tasks           The third requisite of mourning is to con-
of grief work can give a participative, action-    vert the relationship with the deceased from
oriented outlook to the experience of grief as     one of presence to one of memory (Lindemann,
opposed to a perception of grief being a phe-      1944; Parks & Weiss, 1983; Rando, 1987, 1993;
nomenon experienced in a passive manner.           Ruskay, 1996; Sable, 1991; Worden, 1991). The
This also provides a framework for outlining       mourner works to modify and detach the emo-
a significant portion of the helper’s role.        tional ties to the person who has died in prepa-
                                                   ration to live in an altered relationship with
                                                   the dead person. The mourner should not be
Tasks of Mourning
                                                   expected to relinquish all ties to the person
The first task of mourning is to experience and    who died. However, an alteration of the rela-
express outside of oneself the reality of the      tionship must be accomplished. Accomplishing
death (Lindemann, 1944; Parks & Weiss, 1983;       an evolution of this type often provides a
Worden, 1991). This involves confronting the       sense of meaning to the bereaved. Questions
                                                          6 • DEATH AND BEREAVEMENT            41

to ask yourself as a counselor working with        answer to the question “Why?” As Nietzsche
the bereaved:                                      (1968) said, “It was not the suffering that was
                                                   his problem but that the question was want-
  Where is the person in the process of con-       ing to the outcry, Why the suffering?”
  verting the relationship from one of pres-          Questions to ask yourself as a counselor
  ence to one of memory?                           working with the bereaved:
  Is the bereaved resisting any change in
  viewing the relationship as one of pres-           Where is the person in the process of relat-
  ence? If so, what contributing factors may         ing the experience of loss to a context of
  be influencing this (e.g., nature of the rela-     meaning?
  tionship with the deceased, personality of         What were the person’s religious and philo-
  the deceased or of the bereaved)?                  sophical beliefs about life before the loss?
  Does the bereaved think he or she must give        How has the loss altered these beliefs?
  up all forms of bonding with the deceased?
                                                     What is standing between the bereaved
  What can I do as a counselor to help facili-       and their accepting their fate?
  tate a new type of relationship rooted in
  memory (e.g., stimulation of memories,
  new rituals, expression of dreams)?
                                                   TIME INTERVALS AND IMPLICATIONS
                                                   FOR COUNSELORS
   The fourth task of mourning is to develop a
new sense of self-identity based on a life         The time guide for counselors is as fluid as
without the deceased (Lindemann, 1944;             the stages of grief. People move within the
Parks & Weiss, 1983; Ruskay, 1996; Worden,         stages quickly, sometimes going back to the
1991). Role confusion involves the struggle be-    first hours and then jumping well ahead of
tween the we and the I and fears associated        where they actually are, feeling as though
with one’s new autonomy. Research suggests         they have finally finished. This is normal and
that women have more difficulty in this            to be expected. The following is only a de-
struggle than men; however, women are much         scriptive guide (Freeman & Ward, 1998).
more likely than men to seek support and
guidance as they struggle with the develop-
                                                     First 48 hours. The shock of the death can
ment of this new identity.
                                                     be intense, and denial is often strong in the
   Questions to ask yourself as a counselor
                                                     first hours. The emotional response can be
working with the bereaved:
                                                     frightening to the bereaved and friends
                                                     and family members.
  Where is the bereaved in the process of
  forming a new self-identity?                       First week. The necessity of planning the
                                                     funeral and making other arrangements
  Is time a factor influencing where this per-
                                                     usually takes over, and the bereaved may
  son is currently?
                                                     function in an automatic manner. This
  What are the role changes that this person         may be followed by a feeling of letdown
  is experiencing?                                   and emotional and physical exhaustion.
  Are role models of persons who have gone           2 to 5 weeks. There is a general feeling of
  through similar experiences available to           abandonment as family and friends return
  the bereaved?                                      to their own lives after the funeral. Employ-
                                                     ers often expect the bereaved to have recov-
   To complete the grief work, one must relate       ered and to be fully functional on the job.
the experience of loss to a context of meaning.      The insulation of shock may still be in ef-
The bereaved will typically question their           fect, and there may be a sensation of “This
philosophy of life, their values in seeking an       isn’t going to be as bad as I first thought.”
42       PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

     6 to 12 weeks. It is during this time that the      recognition that, although the person will
     shock finally wears off and the reality of          never be forgotten, the pain of the death
     the loss sets in. Emotions range widely,            will no longer need to be the focal point of
     and the person feels out of control and lack        the life of the bereaved. It is during this
     support of family or friends, who may               phase that the terms bereaved and grieving
     think, “That was three months ago. Why              are eased from the vocabulary, and the
     are you feeling bad now?” Some of the ex-           process of living begins in earnest.
     periences during this time are:
                                                         Bowlby (1980) suggests that clinicians
     • Radical changes in sleep patterns.             sometimes have unrealistic expectations about
     • Onset of fear, sometimes paranoia.             the progress people should be making as they
     • Changes in appetite with significant           grieve. He quotes one widow: “Mourning
       weight gain or loss.                           never ends: only as time goes on it erupts less
     • Changes in libido.                             frequently” (p. 101). Rando (1983) describes a
     • Periods of uncontrollable weeping.             V configuration, with bereavement intensity

     • Loss of motivation.                            decreasing in the second year and increasing
     • Fatigue and generalized weakness.              in the third year. This suggests that patterns of
     • Physical symptoms of distress.                 grieving fluctuate over time in a nonlinear
     • Muscle tremors.                                fashion (Gray, 1987). Grief and mourning are
     • Increased need to talk about the de-           uniquely individual processes and no one has
       ceased.                                        the correct timetable for their completion.
     • Extreme mood swings.
     • Desire for isolation.
     • Inability to concentrate or remember.          PATHOLOGICAL GRIEVING: ABNORMAL
                                                      GRIEF RESPONSE
     3 to 4 months. The cycle of good and bad
     days begins. Irritability increases and          Pathological or abnormal grief is the intensifi-
     there is a lowering of frustration tolerance.    cation of grief to the level where the person is
     There may be verbal and physical acting          overwhelmed, resorts to maladaptive behavior,
     out of anger, feelings of emotional regres-      or remains interminably in the state of grief
     sion, and an increase in somatic com-            without progression of the mourning process
     plaints, especially flu and colds, as the        toward completion. It involves processes that
     immune system is depressed.                      do not move progressively toward assimilation
                                                      or accommodation but, instead, lead to stereo-
     6 months. Depression sets in as the sixth-
                                                      typed repetitions or extensive interruptions of
     month anniversary approaches. The event
                                                      healing (Horowitz, Wilmer, Marmar, & Krup-
     of loss is relived and the emotional up-
                                                      nick, 1980, p. 1157).
     heaval seems to be starting all over again.
                                                         Research (de Vries, 1997; Grad & Zavasnik,
     Anniversaries, birthdays, and holidays are
                                                      1996; Horowitz et al., 1980; Rubin & Schechter,
     especially difficult, bringing about re-
                                                      1997; Worden, 1991) suggests that complicated
     newed depression.
                                                      bereavement has to do with four primary fac-
     12 months. The first anniversary of the          tors: relational, circumstantial, historical, and
     death can be traumatic or the beginning of       personality factors.
     resolution, depending on the amount and
     quality of grief work done during the year.
                                                      Relational Factors
     18 to 24 months. This is the time for resolu-
     tion. The pain of separation becomes bear-       Relational factors define the type of relation-
     able, and the bereaved is able to proceed        ship the person had with the deceased. The
     with the living of their own life. There is      most frequent type of relationship that hin-
     an emotional letting go of the deceased, a       ders people from adequate grieving is one
                                                              6 • DEATH AND BEREAVEMENT                  43

involving extreme ambivalence coupled with            extreme emotional distress leads to defensive
unexpressed hostility. Highly narcissistic rela-      withdrawal and can short-circuit the grieving
tionships, in which the deceased represents an        process.
extension of the bereaved, necessitate con-
fronting a loss of part of oneself, thus making
for complications. Highly dependent relation-         SUMMARY
ships are also difficult to grieve. In this type of
relationship, the bereaved loses the source of        When an attachment bond is broken, people
strength that has sustained them, and the re-         experience a grief response. A loss through
sult is an overwhelming sense of abandonment          death is a normal and universal phenomenon
and helplessness. The sense of overwhelming           that requires everyone who experiences it to
helplessness and loss of self-concept tend to         reevaluate and reorganize their attachments
overwhelm any other feelings, including feel-         to significant others. Bowlby (1980) posited
ings related to healthy grief.                        that reorganization of attachment progresses
                                                      through four phases. Reorganization and
                                                      resolution of the grieving process require
Circumstantial Factors                                time for successful completion of the tasks of
Circumstances surrounding a loss may pre-             mourning.
clude or make completion of the grieving pro-
cess difficult or impossible. Uncertainty of the      References
loss, not knowing if a person is truly dead, pre-
                                                      Bowlby, J. (1980). Loss, sadness and depression. New
cludes adequate grieving (e.g., missing chil-
                                                          York: Basic Books.
dren, soldier who is listed MIA, or disaster
                                                      de Vries, B. (1997). Kinship bereavement in later
victims whose bodies are not recovered).                  life: Understanding the variations in cause,
Where no concrete evidence of death is found,             course, and consequence. Omega: Journal of
mourning can be unresolved. Situations where              Death and Dying, 35, 141–157.
multiple losses occur (e.g., Oklahoma City            Freeman, S., & Ward, S. (1998). Death and bereave-
bombing) can make grieving nearly impossible              ment: What counselors should know. Journal
due to the sheer volume involved. Where there             of Mental Health Counseling, 20(3), 216 –226.
are multiple losses in close proximity, it be-        Grad, O., & Zavasnik, A. (1996). Similarities and
comes easier to shut down completely.                     differences in the process of bereavement after
                                                          suicide and after traffic fatalities in Slovenia.
                                                          Omega: Journal of Death and Dying, 33, 243 –251.
Historical Factors                                    Gray, R. (1987). Adolescent response to the death of
                                                          a parent. Journal of Youth and Adolescence, 16(6),
Individual history involving prior experience             511–525.
of complicated grief results in a higher proba-       Horowitz, M., Wilmer, N., Marmar, C., & Krup-
bility of having complications again. Addition-           nick, J. (1980). Pathological grief and the acti-
ally, past losses and separations have an affect          vation of latent self-images. American Journal
on current losses and separations and the ca-             of Psychiatry, 137, 1157–1162.
pacity for future attachments. History of men-        Lindemann, E. (1944). Symptomology and manage-
tal illness can predispose one to complications           ment of acute grief. American Journal of Psychi-
that prevent adequate grief response.                     atry, 101, 141–148.
                                                      Nietzsche, F. (1967). The genealogy of morals and ecco
                                                          homo (Walter Kaufmann, Trans.). New York:
Personality Factors                                       Vintage Books.
                                                      Parks, C., & Weiss, R. (1983). Recovery from bereave-
Grief resolution requires the experiencing of             ment. New York: Basic Books.
universal feelings of helplessness in the face        Rando, T.A. (1983). An investigation of grief and
of existential loss; personality factors are re-          adaptation in parents whose children have
lated to how well or poorly a person copes                died from cancer. Journal of Pediatric Psychol-
with emotional distress. Inability to tolerate            ogy, 8(1), 3 –20.
44     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

Rando, T.A. (1987). The unrecognized impact of         Sable, P. (1991). Attachment, loss of spouse, and
    sudden death in terminal illness and in posi-           grief in elderly adults. Omega: Journal of Death
    tively progressing convalescence. Israeli Jour-         and Dying, 23(2), 129–142.
    nal of Psychiatry and Related Sciences, 24(1/2),   Shuchter, S.R., & Zisook, S. (1990). Hovering over
    125 –135.                                               the bereaved. Psychiatric Annals, 20(6),
Rubin, S., & Schechter, N. (1997). Exploring the so-        327–333.
    cial constructs of bereavement: Perceptions of     Westberg, G. (1962). Goodgrief. Philadephia:
    adjust ment and recovery in bereaved men.               Fortress Press.
    American Journal of Orthopsychiatry, 67,           Worden, J.W. (1991). Grief counseling and grief ther-
    279–289.                                                apy. New York: Springer.
Ruskay, S. (1996). Saying hello again: A new ap-
    proach to bereavement counseling. Hospice
    Journal, 11, 5 –14.




                   STRESS, COPING,
       7           AND WELL-BEING
                   Applications of Theory to Practice


                   John L. Romano



Stress, coping, and well-being are three con-          has been conceptualized and defined differ-
structs that have received much attention in           ently by scholars. Physiologist Hans Selye
the psychological literature and mass media            (1976) defined stress as the “nonspecific re-
markets. The concepts are applicable to chil-          sponse of the body to any demand” (p. 1).
dren and adolescents, as well as adults. In this       Selye’s work followed in the tradition of two
chapter, I present an overview of how each of          other physiologists, Claude Bernard and Wal-
these terms has been conceptualized. The               ter Cannon, who studied the ability of living
overview is followed by a conceptual frame-            organisms to maintain internal physiological
work describing how psychological practi-              constancy despite changes in their external
tioners may interact with clients to help them         environments. Cannon (1932) referred to this
reduce stress, strengthen coping strategies,           internal balance as homeostasis. The phrase
and promote overall well-being.                        “flight or fight,” referring to responses to
                                                       survive a dangerous situation, requires an
                                                       adaptation of the organism to meet the dan-
STRESS                                                 ger, thus changing the organism’s internal
                                                       balance. Although the flight-or-fight re-
Although the layperson may have a general              sponse helps us to survive life-threatening
understanding of the meaning of stress, stress         situations (e.g., a pedestrian rapidly moving
                                                    7 • STRESS, COPING, AND WELL-BEING            45

away from an approaching vehicle), prolonged        and endangering his or her well-being”
arousal that upsets internal physiological bal-     (p. 19). A person’s appraisal of the event and
ance can lead to negative health consequences       his or her ability to cope with the event are
(Rice, 1999).                                       central to Lazarus’s formulation. During a
   Physiological adaptation to stressful life       stressful encounter, a person makes “pri-
events is the theoretical basis for the develop-    mary” and “secondary” appraisals of the situ-
ment of the popular Social Readjustment Rat-        ation. Primary appraisal refers to the amount
ing Scale (SRRS; Holmes & Rahe, 1967). This         of threat the person perceives, and secondary
scale is made up of 43 life events ranked in        appraisal is the person’s evaluation of his or
order of degree of personal difficulty, from 1      her ability to cope with the threat. These ap-
(“death of a spouse”) to 43 (“minor violations      praisals are sometimes fleeting, and the per-
of the law”). Holmes and Rahe hypothesized          son can reappraise a situation as new
that the onset of physical illness was associ-      information is learned. Lazarus furthered our
ated with the number and severity of life           understanding of stress by considering both
events. The life events conceptual framework        the person and the stressful event, whereas
and variations of life event scales have been       previous work focused primarily on either the
developed for other populations, including          person or the stressful event.
children and adolescents (Coddington, 1972;            Stevan Hobfoll (1989), critical of Lazarus’s
Masten, Neemann, & Andenas, 1994) and col-          conceptualization of stress for being circular
lege students (Marx, Garrity, & Bowers,             and overly emphasizing perceptions, brought
1975). Although the Holmes and Rahe re-             a different perspective to psychological stress.
search brought attention to life events, physi-     In his “conservation of resources” model,
ological adaptation, and their impact on            Hobfoll defined stress “as a reaction to the en-
health, the research has been criticized for        vironment in which there is (a) the threat of a
yielding low correlations between life events       net loss of resources, ( b) the net loss of re-
and illness (Dohrenwend & Dohrenwend,               sources, or (c) a lack of resource gain follow-
1984; Somerfield & McCrae, 2000). Sarafino          ing the investment of resources” (p. 516).
(1998) summarized the literature highlight-         Therefore, stress occurs because of an actual
ing other limitations of the SRRS, including        or perceived loss of resources or lack of gain of
the ambiguity of some of the items, variations      resources following investment. Resources
in importance that people attach to the             can include “objects, personal characteristics,
events, and the lack of consideration of con-       conditions, or energies that are valued by the
textual factors related to the life events and      individual or that serve as a means for attain-
onset of illness. For example, financial re-        ment of these objects, personal characteristics,
serves and job satisfaction will impact the sig-    conditions, or energies” (p. 516).
nificance of a job loss, and genetic factors           Rice (1999) has summarized other models
may influence the onset of disease. Lazarus         of stress, including those based on learning,
(1992) also argues that it is difficult to demon-   psychodynamic, and social theory. Although
strate psychosocial influences on health for        each theory of stress has limitations, collec-
some of these same reasons.                         tively they offer different opportunities and
   As a response to the early and almost ex-        options to intervene with clients who are ex-
clusive attention to physiological changes that     periencing stress reactions.
accompany stressful events, and also to ac-
count for individual differences, Lazarus and
his colleagues (Lazarus & Folkman, 1984)            COPING
present a transactional, cognitive model of
stress. They conceptualize stress as “a partic-     Closely aligned to the study of stress are con-
ular relationship between the person and the        ceptual models of how people cope with
environment that is appraised by the person         stress. The study of coping, as with stress, of-
as taxing or exceeding his or her resources         fers different theoretical approaches. Aldwin
46     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

(1994) placed the study of coping into three       affect, psychopathology, and remediation. In
broad categories: person-, situation-, and         recent years, there has been a resurgence of
cognitive-based approaches. Person-based ap-       interest and scholarly attention to positive af-
proaches hypothesize that personality charac-      fect, health and well-being, and prevention.
teristics are major determinants of how people     Seligman and Csikszentmihalyi (2000), intro-
cope with stress. These approaches have their      ducing a special issue of American Psycholo-
roots in psychoanalytic theory and the use of      gist, describe positive psychology as “a
defense mechanisms to cope with stress. Situa-     science of positive subjective experience, pos-
tional approaches argue that coping behaviors      itive individual traits, and positive institu-
are largely influenced by the contextual fac-      tions . . . to improve the quality of life” (p. 5).
tors surrounding the stressor; people cope dif-    Lightsey (1996) presents an extensive litera-
ferently depending on the nature of the            ture review of subjective well-being and psy-
stressor. Cognitive approaches, exemplified by     chological resources and concludes by
Lazarus’s (1993) work, are based on the per-       offering several recommendations for coun-
son’s cognitive appraisal of the situation.        selors (e.g., helping clients develop positive
    Lazarus (1993) defines coping “as ongoing      beliefs about themselves and teaching active
cognitive and behavioral efforts to manage         problem-solving skills to mediate stress reac-
specific external and/or internal demands          tions). Romano (1997) conceptualized “stu-
that are appraised as taxing or exceeding          dent well-being” as “the development of
the resources of the person” (p. 237). Ac-         knowledge, attitudes, skills, and behaviors
cording to Lazarus, coping behaviors can           that     maximize      students’   functioning”
be problem-focused or emotion-focused.             (p. 246). A large body of literature has investi-
Problem-focused coping functions to alter          gated competence, resiliency, and stress re-
the person-environment relationship to im-         sistance in children (Garmezy, Masten, &
prove a stressful situation, whereas emotion-      Tellegen, 1984; Masten & Coatsworth, 1998;
focused coping attempts to moderate the            see also Rak, this volume). After reviewing
emotional distress associated with a stress-       the literature, Benard (1993) concluded that
ful event. An example of the former is seek-       resilient children have four attributes: social
ing legal advice during a marital separation;      competence, problem-solving skills, auton-
joining a support group during the separa-         omy, and a sense of purpose. Folkman and
tion would be an example of the latter. Obvi-      Moskowitz Tedlie (2000) point out that nega-
ously, as these examples show, problem- and        tive affect and distress have dominated the
emotion-focused coping are not mutually ex-        stress and coping literature. They argue for
clusive, and they are both utilized to cope        greater attention to the study of positive af-
with many stressful situations.                    fect and positive outcomes associated with
    The research on stress and coping has          stressful events. Romano and Hage (in press)
grown exponentially during the past 30 years       strongly recommend that greater attention be
(Somerfield & McCrae, 2000). However, some         given to the prevention of psychological dis-
have argued that much of the research offers       turbances and problematic lifestyle behaviors
little of practical value to clinicians (Coyne &   in the training and practice of psychologists
Racioppo, 2000). Others are less pessimistic       and counselors.
but acknowledge the necessity of bridging the
gap between stress and coping research and
clinical practice (Lazarus, 2000).                 FRAMEWORK TO HELP CLIENTS MANAGE
                                                   STRESS, IMPROVE COPING, AND ENHANCE
                                                   WELL-BEING
WELL-BEING
                                                   Mental health practitioners can be instrumen-
Psychology has been dominated by research          tal in helping clients reduce stress, improve
and clinical practice focusing on negative         coping, and strengthen overall well-being to
                                                   7 • STRESS, COPING, AND WELL-BEING             47

improve the client’s psychological, occupa-        Because of these physiological reactions, it is
tional, and social functioning. The framework      important that mental health professionals
here presented is appropriate for individual       help clients understand physical changes that
and group work, as well as for preventive and      may occur during stressful events. Therapists
remedial interventions.                            can explain the flight-or-fight response and
   Clients often seek counseling only after        the physiology of stress, including descriptions
other alternatives to manage a stressor have       of the sympathetic and parasympathetic nerv-
been tried and found lacking (e.g., advice         ous systems and hormonal changes that occur
from family/friends, self-help books). Some-       during a stress response. Clients are usually
times, the stressors are manifested in physical    aware of the physical reactions because they
symptoms such as muscular pain, stomach            have experienced many of them, for example,
distress, or headaches. When clients present       muscle tension, rapid heartbeat, cold fingers,
physical symptoms, it is necessary for thera-      and shallow breathing. Greater understanding
pists to make a referral to a physician to elim-   of the reasons for these changes helps clients
inate organic causes for the symptoms. In          reduce their fears about them and appreciate
other words, it should not be assumed that         the value of coping interventions (e.g., relax-
psychological stress is the primary cause of       ation training) designed to moderate the physi-
the physical symptoms. Excessive stress can        cal effects of stress. A related benefit is a
also be manifested in sleep and eating distur-     greater sense of physiological control. Biofeed-
bances, increased use of alcohol and other         back therapy can help clients learn more subtle
drugs (i.e., legal and illegal and over-the-       physiological information about themselves. In
counter and prescribed medications), and in-       the absence of sophisticated biofeedback
terpersonal difficulties at home and work.         equipment (e.g., electromyograph), clients can
During initial sessions, counselors and psy-       be encouraged to be aware of physiological
chologists need to assess how the client is cur-   changes that accompany stressful situations
rently coping with the stressful situation.        (e.g., an excessively tight grip on a telephone
This assessment should include questions           during an important call).
about alcohol and drug use, episodes of de-        Cognitive Awareness. Cognitive psychology
pression, suicidal ideation, and incidences of     has made us very aware of the role of private
violent behaviors. In addition, questions          thoughts in emotional disturbance (Beck &
about sleep patterns, eating behavior, and         Weishaar, 2000; Ellis, 2000). Cognitions con-
physical activity should be asked.                 tribute significantly to stress reactions, and a
   The framework includes three components:        discussion of the role of private thoughts in
(1) increase awareness of behaviors and reac-      stress reactions should take place with the
tions associated with a stressful situation, (2)   client. As with the physiological dimension
improve coping strategies, and (3) strengthen      above, clients usually understand from their
well-being.                                        own experience how thinking behaviors in-
                                                   fluence their emotions.
Increase Awareness                                    In Lazarus’s (1984) conceptualization of
                                                   stress, a person’s cognitive appraisal of a situa-
One goal of many preventive and remedial           tion is related to a stress reaction. Clients can
psychological interventions is to increase the     be instructed to monitor their thoughts sur-
participant’s or client’s personal awareness.      rounding stressful situations; in this way, they
When a presenting issue is stress-related, it is   record their stress appraisals and become
important that clients gain increased aware-       aware of irrational and distorted self-talk. A
ness of their personal responses to the stress-    thoughts diary helps clients monitor their self-
ful situation.                                     talk by recording over several days their strong
Physiological Awareness. Selye’s (1976) contri-    emotional responses (e.g., anxiety, anger, sad-
butions made us acutely aware of physiologi-       ness), the events that precipitated the emo-
cal changes that accompany stressful events.       tions, and the thoughts that accompanied the
48     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

emotions and events. A client examines with          engage the parasympathetic nervous system,
the counselor this record of self-talk and how       creating a relaxation response. These interven-
it may be contributing to stress reactions.          tions give clients tools or strategies to help the
Lifestyle Awareness. Lifestyle patterns con-         body return to an increased level of homeosta-
tribute to stress reactions. For example, exces-     sis. As the parasympathetic nervous system
sive caffeine, limited physical activity, lack of    becomes engaged, physiological changes
proper nutrition, poor sleep habits, weak so-        occur; for example, heart rate is slowed, hands
cial networks, and time mismanagement may            and fingers become warmer, and muscle ten-
not only add to the distress of a situation, but     sion is reduced. A major advantage of teaching
interfere with a person’s ability to cope with       clients strategies to influence their physiology
the situation. Clients need to learn how             is the sense of control they experience over
lifestyle behaviors contribute to stress. For ex-    their physiological reactions to a stressful en-
ample, excessive caffeine contributes to over-       counter. One example is teaching clients the
stimulation of the nervous system; poor sleep        difference between stress-induced breathing
habits and low social support interfere with         (i.e., upper chest movement, shallow breaths)
healthy coping behaviors; poor nutrition in-         and relaxed breathing (i.e., abdomen move-
creases the risk of illness. Different types of      ment, deeper breaths). One form of relaxed
record-keeping or diaries help clients become        breathing is called diaphragmatic breathing
aware of these and other lifestyle behaviors.        because it utilizes the diaphragm, a muscle at
Examples include asking clients to record all        the bottom of the chest cavity, to regulate the
that they eat and drink over several days and        flow of oxygen into and out of the body. Di-
keeping a time diary to monitor use of time.         aphragmatic breathing is sometimes referred
                                                     to as natural breathing because newborn in-
   The major goals of this component are to (1)
                                                     fants instinctively breathe with the di-
teach an understanding of the relationship of
                                                     aphragm. Stress reactions disrupt this natural
physiology, thoughts, and lifestyle to stress; (2)
                                                     tendency to breathe with the diaphragm.
encourage clients to increase their awareness
                                                     Clients can be given instruction and practice
of their reactions to stressful situations; and
                                                     in diaphragmatic breathing and asked to uti-
(3) monitor how they are presently coping
                                                     lize this strategy during stressful encounters.
with the situation. Self-awareness is important
                                                     Diaphragmatic breathing and other forms of
as an initial step in the change process.
                                                     psychophysiological interventions have the ef-
                                                     fect of inducing emotional calmness as they
                                                     engage the parasympathetic nervous system.
Improve Coping Strategies                            Breathing techniques have advantages over
The second component of this framework is            other forms of psychophysiological interven-
helping clients change, improve, or strengthen       tions because they can be implemented with
their coping strategies to better manage a           little or no notice from others. However, clients
stressful situation. Various interventions are       must remember to utilize them; I have encour-
available in the three domains of physiology,        aged people to make notes to themselves
cognition, and lifestyle. Interventions related      (“breathe with my diaphragm”) in anxiety-
to these domains may overlap and are not mu-         producing situations (e.g., public speaking).
tually exclusive. Interventions can be utilized      Cognitive Change. Cognitive-behavior theory
for remedial and preventive purposes and in          (Beck & Weishaar, 2000; Ellis, 2000) has pro-
individual and group applications.                   vided numerous techniques and strategies to
Physiological Change. The flight-or-fight re-        help clients change thinking patterns that
sponse disrupts physiological homeostasis            contribute to stress reactions. One type of
during a stressful encounter. The sympathetic        strategy is cognitive restructuring, in which
nervous system predominates during the re-           clients learn to replace irrational and dis-
sponse. Interventions such as relaxation train-      torted beliefs and thoughts with self-
ing, diaphragmatic breathing, and meditation         statements that are more rational and
                                                    7 • STRESS, COPING, AND WELL-BEING            49

realistic. Changing self-defeating and stress-      1993). They also may underestimate how mis-
producing thoughts to those that are more self-     use of time and weak social support networks
enhancing will reduce stress reactions. In          may contribute to stress.
terms of Lazarus’s (1984) concepts of stress and       Lifestyle changes must be introduced grad-
coping, cognitive restructuring strategies have     ually so that clients do not become discour-
the potential to help clients appraise stressful    aged and lose motivation to change. Discuss
situations more accurately. If a client regularly   with clients changes that they are most moti-
uses words such as “should,” “always,”              vated to make. Once the focus of change has
“never,” “everybody/nobody,” and “can’t,”           been decided on, a change strategy can be de-
these are signs that the client’s thought pat-      veloped, implemented, and regularly evalu-
terns may be self-defeating. Suggesting that        ated for effectiveness.
clients utilize more appropriate language (e.g.,
“some,” “most people,” “I chose” rather than “I
should”) will reduce stress. Other cognitive        Strengthen Well-Being
strategies include thought stopping and cogni-
                                                    The final component of this model teaches
tive rehearsal, which are techniques to discour-
                                                    clients behaviors and strategies to enhance
age the use of self-defeating thoughts and
                                                    their overall well-being to buffer the effects of
promote self-enhancing thoughts.
                                                    future stressors and life changes. In addition
   One stress management intervention uti-          to physiological, cognitive, and lifestyle do-
lizing cognitive strategies along with other        mains, it is recommended that clients period-
techniques is called stress inoculation train-      ically review other areas of their lives,
ing (SIT). SIT was developed by Meichen-            including spiritual, family, and career. In-
baum and his colleagues (Meichenbaum &              cluded in these areas are themes of personal
Jaremko, 1983) to help people prepare for           values, life meaning, hope, optimism, and life
stressful events. SIT inoculates people against     satisfaction (e.g., family, career, and interper-
the effects of stress situations through educa-     sonal relationships).
tion, coping skills training, and application.         Kobasa (1979) has studied people who are
Lifestyle Change. Mental health professionals       resistant to the negative health effects of
are well positioned to inform people about          stressful life events. She hypothesized that
lifestyle behaviors that contribute to stress       these people are characterized by a “hardy
and those that may buffer the effects of stress.    personality”; that is, they are people who ex-
As behavior change experts, counselors are          hibit a sense of personal control, are commit-
well qualified to initially assess problematic      ted to their endeavors, and feel challenged
lifestyle behaviors and suggest possible            by them. According to Kobasa, these charac-
change strategies. Psychologists and coun-          teristics serve as protective factors in stress-
selors may need to refer to other professionals     ful situations.
for consultation in areas that are beyond their        A holistic model of personal develop-
expertise (e.g., nutritionist, chemical depen-      ment, addressing several dimensions of the
dency counselor, exercise physiologist). At         human condition, is highly recommended
times, referral to a clergy person may be nec-      to strengthen well-being. Romano (1984) de-
essary. Most important, however, counselors         veloped a holistic model of stress manage-
need to teach clients how lifestyles that pro-      ment in the form of a university course and
mote well-being will help to manage stress          reported promising results. Recently, Hoff-
and enhance overall health. For example, peo-       man and Driscoll (2000) articulated a broadly
ple are bombarded in the national media             conceptualized biopsychosocial model of
about the health benefits of physical exercise      health promotion and disease prevention to
and diets low in sugar and saturated fats.          address health needs. Coping styles and stress
However, clients may be less informed about         management are important components of the
the potential benefits of physical exercise as a    model. The Wheel of Wellness is another com-
stress management strategy (Long & Flood,           prehensive example of a holistic model for
50     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

health and well-being presented by Myers,                     biopsychosocial model of health status. In
Sweeney, and Witmer (2000).                                   S.D. Brown & R.W. Lent (Eds.), Handbook of
   Stress, coping, and well-being are impor-                  counseling psychology (3rd ed., pp. 532–567).
tant psychological constructs that have en-                   New York: Wiley.
joyed a rich theoretical and applied history.            Holmes, T.H., & Rahe, R.H. (1967). The social read-
                                                              just ment rating scale. Journal of Psychosomatic
Although much more needs to be learned
                                                              Research, 11, 213 –218.
about them, there is sufficient research evi-
                                                         Kobasa, S.C. (1979). Stressful life events, personality
dence to recommend the application of these                   and health: An inquiry into hardiness. Journal
constructs for preventive and remedial appli-                 of Personality and Social Psychology, 37, 1–11.
cations by mental health practitioners.                  Lazarus, R.S. (1992). Four reasons why it is diffi-
                                                              cult to demonstrate psychosocial inf luences
                                                              on health. Advances, the Journal of Mind-Body
References
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Aldwin, C.M. (1994). Stress, coping, and development:    Lazarus, R.S. (1993). Coping theory and research:
     An integrative perspective. New York: Guilford           Past, present, and future. Psychosomatic Medi-
     Press.                                                   cine, 15, 234 –247.
Beck, A.A., & Weishaar, M.E. (2000). Cognitive           Lazarus, R.S. (2000). Toward better research on
     therapy. In R.J. Corsini & D. Wedding (Eds.),            stress and coping. American Psychologist, 55,
     Current psychotherapies (pp. 241–272). Itasca,           665 –673.
     IL: Peacock.                                        Lazarus, R.S., & Folkman, S. (1984). Stress, ap-
Benard, B. (1993, November). Fostering resiliency             praisal, and coping. New York: Springer.
     in kids. Educational Leadership, 44 – 48.           Lightsey, O.S. (1996). What leads to wellness? The
Cannon, E.B. (1932). The wisdom of the body. New              role of psychological resources in well-being.
     York: Norton.                                            The Counseling Psychologist, 24, 589–735.
Coddington, R.R. (1972). The significance of life        Long, B.C., & Flood, K.R. (1993). Coping and work
     events as etiologic factors in the diseases of           stress: Psychological benefits of exercise. Work
     children: II. A study of a normal population.            and Stress, 7, 109–119.
     Journal of Psychosomatic Research, 16, 205 –213.    Marx, M.B., Garrity, T.F., & Bowers, F.R. (1975).
Coyne, J.C., & Racioppo, M.W. (2000). Never the               The inf luence of recent life experiences on the
     twain shall meet? Closing the gap between                health of college freshmen. Journal of Psychoso-
     coping research and clinical intervention re-            matic Research, 19, 87–98.
     search. American Psychologist, 55, 655 –664.        Masten, A.S., & Coatsworth, J.D. (1998). The devel-
Dohrenwend, B.S., & Dohrenwend, B.P. (1984). Life             opment of competence in favorable and unfa-
     stress and illness: Formulation of the issues.           vorable environments: Lessons from research
     In B.S. Dohrenwend & B.P. Dohrenwend                     on successful children. American Psychologist,
     (Eds.), Stressful life events and their contexts.        53, 185 –204.
     New York: Prodist.                                  Masten, A.S., Neemann, J., & Andenas, S. (1994).
Ellis, A. (2000). Rational emotive behavior ther-             Life events and adjust ment in adolescents:
     apy. In R.J. Corsini & D. Wedding (Eds.), Cur-           The significance of event independence, desir-
     rent psychotherapies (pp. 168–204). Itasca, IL:          ability, and chronicity. Journal of Research on
     Peacock.                                                 Adolescence, 4, 71–97.
Folkman, S., & Moskowitz Tedlie, J. (2000). Positive     Meichenbaum, D., & Jaremko, M.E. (1983). Stress
     affect and the other side of coping. American            reduction and prevention. New York: Plenum
     Psychologist, 55, 647–654.                               Press.
Garmezy, N., Masten, A.S., & Tellegen, A. (1984).        Myers, J.E., Sweeney, T.J., & Wit mer, J.M. (2000).
     The study of stress and competency in children:          The Wheel of Wellness counseling for wellness:
     A building block for developmental psycho-               A holistic model for treat ment planning. Jour-
     pathology. Child Development, 55, 97–111.                nal of Counseling and Development, 78, 251–266.
Hobfoll, S.E. (1989). Conservation of resources: A       Rice, P.L. (1999). Stress and health. Pacific Grove,
     new attempt at conceptualizing stress. Ameri-            CA: Brooks/Cole.
     can Psychologist, 44, 513 –524.                     Romano, J.L. (1984). Stress management and well-
Hoffman, M.A., & Driscoll, J.M. (2000). Health pro-           ness: Reaching beyond the counselor’s office.
     motion and disease prevention: A concentric              Personnel and Guidance Journal, 62, 533 –536.
                                                                             8 • THE FAT CLIENT           51

Romano, J.L. (1997). School personnel training for       Seligman, M.E.P., & Csikszent mihalyi, M. (2000).
    the prevention of tobacco, alcohol, and other             Positive psychology: An introduction. Ameri-
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    Education, 27, 245 –258.                             Selye, H. (1976). The stress of life. New York: Mc-
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Sarafino, E.P. (1998). Health psychology: Biopsychoso-        plications. American Psychologist, 55, 600–625.
    cial interactions (3rd ed.). New York: Wiley.




                    THE FAT
        8           CLIENT


                    Janet Melcher and Gerald J. Bostwick Jr.




On a daily basis, people in the United States are           The word “fat” will be used in this chapter
bombarded with images of ideal personal ap-              when referring to clients. As Barron and Lear
pearance. Mass media communications suggest              (1989) point out, the word “obese” is used in a
that achieving the correct appearance will lead          medical context and therefore suggests that
to acceptance, success, and overall happiness in         fat is a disease. “Overweight” suggests that
life. The current standards for attractiveness in-       there is really a correct weight that one is
clude size specifications. It is not surprising,         over. The word fat is used to acknowledge and
then, that some people who seek mental health            honor the most accurate description of the
care may be concerned about food and weight              client, in the hope that the word’s derogatory
issues either because their actual size is differ-       connotation will fade.
ent from what society deems desirable, or be-               If the fat person expresses concern about
cause they have become obsessed with                     food and weight, the mental health practi-
maintaining a body size that already meets or            tioner needs to expand the scope of the assess-
exceeds societal standards. Concerns about               ment and intervention plan by considering the
food and weight bring anguish in many forms.             following:
The following discussion focuses specifically
on providing help to those persons who are               • The influence of social/cultural beliefs
truly considered heavier than average or obese             and messages about size.
by the mental health practitioner.                       • Biological factors that affect size.
52     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

• Psychological ramifications of being heav-       the number one health problem in this country.
  ier than average in a society that values        Obesity became a disease to be treated by
  thinness.                                        physicians; the remedy for the disease was the
                                                   weight-loss diet (Bennett & Gurin, 1982; Seid
                                                   1989).
SOCIAL/CULTURAL BELIEFS AND                           While the health care industry was busy
MESSAGES ABOUT SIZE                                embracing the notion that lower body weight
                                                   was healthy for all, the fashion industry came
Today in Western culture, the slender body         along to firmly implant an association between
shape is placed before the public as a standard    thinness and beauty in the consciousness of
to achieve, particularly for women. This preoc-    the culture (Seid, 1989). In the 1960s, the ap-
cupation with thinness is a relatively recent      pearance of the famous fashion model Twiggy
phenomenon. Prior to the late 1800s and early      (5′7″ and 98 pounds) marked the beginning of
1900s, thinness was often considered un-           a more severe standard for thinness, which
healthy and unattractive. One factor that          continues to be idealized today (Seid, 1994).
brought about the change in attitude was the          In the decades after the 1960s, the models
expansion of women’s roles around the turn of      for female beauty became increasingly thinner
the century. In the late 1800s, feminist ideas     and less likely to resemble what the average
emerged. Some women were attending college         American woman could realistically achieve.
and many were finding jobs outside the home.       For example, Garner, Garfinkel, Schwartz, and
At the same time, the view that women were         Thompson (1980) found that the Miss America
too frail to be physically active was supplanted   contestants during the period from 1959 to
by the view that healthy women should be ath-      1978 showed a trend toward decreasing
letic. Thus, women began to enjoy more overall     weights at the same time that American women
physical freedom. The expansion in women’s         were increasing in weight. In an update of this
roles necessitated changes in women’s fash-        research, Wiseman, Gray, Mosimann, and
ions. The cumbersome clothing styles of the        Ahrens (1992) found that the Miss America
past were simply no longer practical. The fash-    contestants’ body weights continued to de-
ion industry responded by designing more           crease between 1979 and 1988. During this pe-
functional clothing. The new styles were more      riod, the reported Miss America body weights
revealing, making it more difficult for women      were 13% to 19% below the weights that would
to use clothing for body shape enhancement.        be expected for women of their ages. These au-
Because clothing could no longer be used to        thors point out that maintaining a weight of
cosmetically shape the body, the body became       15% below the expected weight is one criterion
the object to be shaped (Bennett & Gurin,          for the diagnosis of anorexia nervosa.
1982; Seid, 1989, 1994).                              Today, the pursuit of thinness remains
   By the middle of the century, the changing      quite popular. For instance, results of a recent
attitudes about appropriate weight and size        survey of U.S. college students (Centers for
were reinforced by a Metropolitan Life Insur-      Disease Control and Prevention, 1997) indi-
ance Company retrospective study (as cited in      cated that 41.6% of students considered them-
Bennett & Gurin, 1982) that examined the rela-     selves to be overweight, even though only
tionship between weight and mortality rates.       20.5% were classified as overweight. Female
Despite the biased samples and questionable        students were more likely to consider them-
data analyses, the findings were generalized       selves overweight than male students. The re-
to the entire population. The proliferation of     port states that 46.4% of the college student
papers generated by this insurance company’s       respondents were attempting to lose weight.
scientist was instrumental in accelerating the     Overall, one-third of college students have
change in attitudes about weight and health.       used dieting as a means to control weight and
By the early 1950s, obesity was identified as      about one-half have used exercise.
                                                                    8 • THE FAT CLIENT        53

   Media messages continue to promote the         found that there was a correlation between
concept that weight loss is a goal that the ac-   obesity and socioeconomic status, with the
ceptable person will achieve. The messages        highest percentage of obese women falling
mainly affect females. Levine and Smolak          into the lowest socioeconomic status group.
(1996) found that weight loss is glorified in     Men showed a similar trend to a lesser de-
magazines and through televised messages          gree (Moore, Stunkard, & Srole, 1962). More
that adolescent girls and young women are         recently, a seven-year follow-up of subjects
likely to see. Wertheim, Paxton, Schutz, and      who were overweight during adolescence and
Muir (1997) found that girls responded to         early adulthood found that the women had
the thin ideal pictured in the media by feel-     completed fewer years of school, were not as
ing pressured to be thin. Pinhas, Toner, Ale,     likely to be married, and were more likely to
Garfinkel, and Stuckless (1999) report that       live in poverty than women who had not been
the women in their study felt angrier and         overweight. These researchers believe that
had an increase in depressed mood after           their findings support the position that so-
looking at pictures of the thin models from       cioeconomic status is a consequence of being
common fashion magazines. While conduct-          overweight, and they question the assump-
ing a content analysis of popular magazines,      tion that being overweight is due to socioeco-
Malkin, Wornian, and Chrisler (1999) discov-      nomic status (Gortmaker, Must, Perrin, Sobol,
ered that 94% of women’s magazines showed         & Dietz, 1993).
thin females on the cover. They also found           Rothblum and associates (1990) found that
that the magazine covers displayed messages       the very obese participants in their research
about weight that were positioned next to         reported experiencing various types of em-
other messages with the implication that          ployment discrimination. Both obese and
weight loss will lead to an improved life.        very obese people also reported school vic-
   When reviewing the literature on weight        timization, including being called negative
loss issues, several themes emerge (Kilbourne,    weight-related names, being excluded from
1994; Nichter & Nichter, 1991; Seid, 1989):       sports or social activities, and being victims
                                                  of discrimination by teachers.
• Advertisers have an interest in keeping            Access to appropriate medical care is a
  consumers dissatisfied with themselves          concern for obese people. Some have been de-
  because profit depends on selling some-         nied health insurance because of their weight
  thing that the consumer lacks. There is no      (Rothblum, Brand, Miller, & Oetjen, 1990).
  incentive to tell consumers, especially         Some may not have adequate health care sim-
  women, that they are perfectly acceptable       ply because they are poor and cannot afford
  just as they are.                               health insurance and preventive care (Roth-
• To ward off uncomfortable reminders that        blum, 1994). Some are reluctant to seek med-
  life is full of uncertainties, great value is   ical care because they anticipate receiving
  placed on “being in control” in our culture.    abuse and admonitions about weight from
  Weight has become symbolically linked to        their physicians, regardless of the symptom
  control. Those considered fat are viewed as     for which treatment is sought (Burgard &
  violators of the mandate for control and are    Lyons, 1994).
  consequently judged as lacking in virtue.          Finally, Seid (1989) notes that the cruelest
• Satisfying versus suppressing the appetite      and most damaging thing the fashion indus-
  for food has become a moral issue for per-      try did in the 1960s was to convey the idea
  sons of all sizes, especially for fat people.   that anyone could become thin. The health
                                                  care industry supported this notion as well.
   Naturally, the impact of living in this so-    The assumption that thinness is attainable by
cial context may be quite significant for the     everyone persists. This view is particularly
fat person. As early as 1962 researchers          distressing given the evidence that biological
54     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

realities are in conflict with the cultural man-       these health benefits disappear with the
date to be thin.                                       regaining of weight and often are more
                                                       problematic than prior to the weight loss
                                                       (Garner & Wooley, 1991).
BIOLOGICAL FACTORS THAT AFFECT SIZE                •   Weight cycling (repeatedly losing and re-
                                                       gaining weight) is associated with higher
The set point theory holds that the body has a         rates of death from coronary heart disease
built-in system that determines how much fat           and death from all causes (Brownell &
is needed (Nisbett, 1972). When a person tries         Rodin, 1994; Lissner et al., 1991).
to reduce the fat stores through a weight-loss     •   Persons who gain a modest amount of
diet, biological changes occur. These changes          weight during adulthood have the lowest
are actually designed to help the body survive         mortality rates, and weight loss is associ-
through times of famine. Metabolic rates de-           ated with higher mortality rates (Andres,
crease and calories are burned more slowly to          Muller, & Sorkin, 1993; Pamuk et al.,
defend the fat stores. The dieter may notice           1992).
that weight loss slows or stops altogether.        •   Normal daily calorie intake for adults may
Soon, the dieter will experience intense               range from 2,400 to 3,000 calories per day.
hunger and may feel compelled to eat. When             Most weight-loss diets prescribe 945 to
eating occurs, weight is gained more easily            1,200 calories per day. The World Health
because the metabolic rate is lowered (Ben-            Organization states that 900 or fewer calo-
nett & Gurin, 1982; Leibel, Rosenbaum, &               ries qualifies as starvation (www.naafa.org).
Hirsch, 1995). Most dieters will regain the        •   Hunger is managed best through eating
weight lost within two to five years and many          at regular, predictable intervals (Wooley,
will weigh more than they did before the diet          Wooley, & Dyrenforth, 1979).
(Garner & Wooley, 1991).
    When working with the fat client, the men-        Because there are hazards associated with
tal health practitioner should keep the follow-    weight loss, experts recommend lifestyle
ing in mind:                                       changes that promote health for persons of
                                                   any size (I. Kedd, 2000). This involves incre-
• Fat people do not eat more than lean people.     mental, moderate changes in eating and exer-
  A fat person may need to eat considerably        cise habits that can be realistically sustained
  less than the lean person to maintain an av-     over time. The health benefits are immediate.
  erage body size (Garner & Wooley, 1991).         For example, a study comparing fitness levels
• Different people can eat the same amount         in overweight and normal-weight men found
  of food and have very different body sizes       a lower risk of mortality in the physically fit
  (Bouchard et al., 1990).                         regardless of size (Barlow, Kohl, Gibbons, &
• Genes appear to influence body fatness,          Blair, 1995). Although there is much conflict-
  and the childhood environment has little         ing information about healthy eating, authori-
  or no effect (Stunkard et al., 1986).            ties seem to agree that eating a varied diet
• A body mass index (BMI) in the 26 to 28          that incorporates favorite foods, fruits, veg-
  range is considered over the ideal weight.       etables, and whole grains is most beneficial;
  BMI is weight in kilograms divided by the        they also recommend limiting portions of
  square of height in meters (kg/m2). Longi-       foods high in fat (Berg, 1993; Burgard &
  tudinal studies show that BMIs in this           Lyons, 1994). Research indicates that blood
  range do not necessarily result in increased     pressure can be reduced by diet content
  mortality rates (Ernsberger & Haskew,            (Appel et al., 1997). Also, risk factors for coro-
  1987; Troiano, Frongillo, Sobal, & Levitsky,     nary artery disease can be reduced by using a
  1996).                                           combination of dietary content and exercise
• Weight loss can reduce cholesterol and blood     even for people who remain fat (Barnard,
  pressure and improve glucose tolerance, but      Ugianskis, Martin, & Inkeles, 1992).
                                                                      8 • THE FAT CLIENT         55

PSYCHOLOGICAL RAMIFICATIONS OF BEING               perennial dieter, the decision to stop dieting
FAT IN A SOCIETY THAT VALUES THINNESS              is a significant psychological step that means
                                                   parting with the dream of being thin. The fat
In both the general and professional literature,   client may need time to accept the fact that
there has been a tendency to view a person’s       permanent size reduction is an unattainable
weight-loss failures as the result of a psycho-    goal and to develop a new way of thinking
logical defect. Of course, fat people have the     about self and food.
same range of difficulties and disturbances as        For some people, even with adequate food
people of any size, but studies have found that    intake over time, significant overeating or
the rate of psychopathology in the obese popu-     binge eating may continue. When the person
lation is similar to the rate in the nonobese      has experienced food deprivation, even if in-
population. So the idea that people are fat be-    termittently, food can take on exaggerated
cause they have psychological disturbance has      importance. The good feeling one gets by sat-
been refuted (Stunkard & Wadden, 1992).            isfying hunger seems to get confused with
However, some psychological symptoms that          soothing emotional pain. Overeating consis-
fat people present to mental health profession-    tently used to ease emotional pain does not
als are actually the offshoots of being fat in a   occur in all cases, as the popular media sug-
society that values thinness. Symptoms that        gests. When overeating does occur in this
are really the psychological ramifications of      manner, however, it can be quite alarming for
being fat include distorted relationships with     the individual.
food, problematic emotions associated with            Many unpleasant emotional reactions are
food deprivation, and self-deprecating re-         associated with food deprivation. These in-
sponses to the prejudices about size.              clude irritability, anxiety, mood swings, and
    Many fat people have tried weight-loss         depressive symptoms (Garner & Wooley, 1991;
diets. Often, they want very much to comply        Polivy, 1996). Adequate nourishment is needed
with societal expectations. For some, the re-      for optimal psychological functioning. When
peated efforts to lose weight have resulted in     eating returns to normal, these emotional
distorted relationships with food, which may       changes may subside.
become manifest in the following ways:                Finally, fat people have different psycho-
                                                   logical reactions to societal prejudice and dis-
• Binge eating and some overeating can be a        crimination. Those who subscribe to the view
  consequence of the body’s push to restore        that weight is under their control accept soci-
  fat after restrictions in food intake. This      ety’s condemnation of their size and consider
  particular eating compulsion is a biological     themselves at fault for their own condition. In
  survival mechanism and is not necessarily        contrast, some fat people recognize the distor-
  indicative of psychological pathology (Po-       tions in the media and in the public’s think-
  livy, 1996; Telch & Agras, 1993).                ing about weight and do not accept the view
• The fat person has been trained and encour-      that they are defective or deficient (Crocker,
  aged to limit food intake, so that normal eat-   Crornwell, & Major, 1993). Responses to this
  ing (eating in response to internal hunger       hostile environment range from total self-
  signals) seems forbidden (Polivy, 1996).         deprecation to fat activism.
• Even when not overeating, the fat person
  may be apologetic about the amount of
  food consumed and may even feel the need         ASSESSMENT
  to hide when eating (Polivy, 1996).
                                                   For clients of any size, especially females, food
   Unfortunately, the amount of food required      and weight issues may be a concern. The fat
to stabilize eating patterns and improve emo-      client may or may not express concern about
tions will often lead to fears of weight gain.     these issues. As part of the usual assessment
Weight gain is perceived as failure. For the       process, the mental health practitioner may
56     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

mention that food and weight issues are of         behaviors that would put the eating pattern in
great concern to many people living in this        the bulimic category.
culture and then may ask if these issues are a        For many practitioners and clients as well,
concern for the client. If the client indicates    there can be a great temptation to focus on
that there are no concerns in this area, the ex-   how much food the client is eating with little
ploration is ended. The mention of the subject     attention to the overall pattern of eating. If
gives the client permission to revisit the topic   the person is truly binge eating or consis-
at a later time. If the client expresses concern   tently overeating, the usual pattern includes
about food and weight issues, the assessment       some period of deprivation that precedes the
should be expanded to include a discussion of      overeating. The client could be experiencing
dieting history, current eating patterns, level    a rebound from a recent weight-loss diet or
of physical activity, and expectations about       perhaps the client does not eat all day and
any problems that will be solved as a result of    then eats continuously at night. The depriva-
resolving food and weight issues.                  tion must be understood and addressed to
                                                   help the client become free of food obses-
                                                   sions. To obtain the pertinent information
Dieting History
                                                   about eating patterns, the following ques-
The dieting history provides some indication       tions may be asked:
of clients’ long-term relationship with food
as well as their understanding of why past         • It is helpful to know the details about the
attempts at resolving food and weight issues         most recent diet. What type of diet did you
have not been successful. The following              try and when did it occur? What have you
questions can be used to explore the dieting         noticed about eating patterns since the
history:                                             diet?
                                                   • Describe the way you eat on a typical day.
• How many diets have been tried?                    What do you consider to be a good eating
• What types of diets were tried?                    day? What is a bad day? Do you have foods
• Approximately when did the dieting take            that you consider good or bad? If so, please
  place?                                             explain.
• How much weight was regained after each          • Do you see a connection between your
  diet?                                              emotions and your eating pattern?
• Were there any emotional changes when            • Most people overeat at times. Some people
  dieting?                                           feel that they overeat constantly. How
• What is your understanding of the reason           would you describe your overeating?
  for lack of success with weight loss?            • Do you ever binge eat? If so, how often,
                                                     when does the binge occur, and what is
                                                     consumed?
Current Eating Patterns
                                                   • Sometimes, people try to maintain a lower
Clients’ eating patterns may range from nor-         weight by trying not to eat, by vomiting
mal to somewhat problematic to so troubled           after eating, by using laxatives, or by exer-
that a formal eating disorder diagnosis is war-      cising extensively. Have you used any of
ranted. The practitioner may discover that a         these methods to control weight?
client’s eating falls within a normal pattern
even when the client defines the eating as
                                                   Exercise
problematic: The client believes that some-
thing must be wrong with the eating pattern        A review of the exercise history and current
because a heavy weight is maintained. Clients      activity level is important for several reasons.
may express some conflicts about food be-          Some clients may be supporting their own
cause eating has been discouraged. Some            health currently by engaging in regular physi-
clients may be engaging in binge-purge             cal activity, but they may be discouraged
                                                                        8 • THE FAT CLIENT        57

because significant weight loss has not oc-             she must be doing something wrong be-
curred. Some may have gained weight after an            cause she is heavier than average. She may
injury or illness resulted in a need to limit ac-       be asking for help at this moment in her
tivity, so accommodations may be needed for             life because of some normal developmental
the person to remain active. Some may be re-            shift, which causes her to reflect upon
luctant to exercise because they fear being             where she is in life. For example, she may
ridiculed if exposed to the public eye. The             turn 30 and become more concerned about
questions related to exercise include:                  the fact that she’s not married. She believes
                                                        that weight loss is required in order to
• Do you exercise or engage in any type of              meet this and other life goals;
  physical activity?                                •   Well-Adjusted Overeater—this person func-
• Do you have any physical problems that re-            tions well. However, she may be overeating
  quire you to limit your physical activity?            or perhaps binge eating because she has
• If you are not currently engaged in any               been dieting and/or excessively exercising;
  kind of regular physical activity, do you         •   Emotionally Troubled Normal Eater—this per-
  have any concerns that prevent you from               son is not overeating, but believes that an
  being active (e.g., don’t want to put on a            eating problem exists because she is heav-
  leotard and go to the aerobics class with all         ier than average. She has emotional issues
  the thin women)?                                      that cause problems in functioning but
                                                        these are not necessarily related to her
                                                        weight;
Goals Accomplished by Losing Weight
                                                    •   Emotionally Troubled Overeater—this person
People of all sizes focus energy on losing              is involved in overeating or problematic
weight in part because being thinner may be             eating and has co-existing emotional prob-
the means by which another goal is attained.            lems. In this case, the social worker still
Perhaps the weight loss is intended to bring            needs to know whether there has been re-
greater social acceptance or improved health.           cent food deprivation because, as in the
Questions should be designed to help clients            other cases, the effort to diet is contribut-
reveal the goal(s) that are ultimately to be ac-        ing to the eating problem. For this individ-
complished by losing weight. Responses to               ual, when food deprivation no longer exists
the following questions will help the practi-           there may be continued use of food to help
tioner to further clarify the clients’ goals:           with managing a variety of emotions (e.g.,
                                                        anxiety, depression); and,
• What was happening in your life that made         •   Normal and Knows It—this person is heav-
  you decide to try to lose weight?                     ier than average, has accepted her size,
• How would your life be better if you lost             functions well, and does not overeat.
  weight?                                               However, she may feel lonely because few
                                                        people understand her situation and she
   When the information about dieting, eat-             may feel exhausted by societal discrimi-
ing patterns, exercise, and goals to be ac-             nation. (p. 200)
complished by weight loss is added to the in-
formation gathered in the usual assessment
process, the client’s issues usually fall into      INTERVENTION
one of five categories. As we delineated in an
earlier article (Melcher & Bostwick, 1998) the      With the possible exception of the “normal
categories are:                                     and knows it” client, all of the clients in the
                                                    four remaining categories need information
• Normal but Doesn’t Know It—she functions          about the arbitrary nature of size stipulations
  well in all or most areas of her life and eat-    in Western culture, about the pitfalls of
  ing is actually normal. She believes that         weight-loss dieting, and about the option of
58     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

living in a manner that promotes health             emotional problems, proceed with treatment as
regardless of size. An ideal way to transmit        usual. If one mental health practitioner is work-
such information is through a psychoeduca-          ing with the food and weight issues as well as
tional group. In a psychoeducational group,         the more general mental health concerns, dis-
clients receive information, have the opportu-      cussion of the two areas can be blended. If
nity to discuss how the information applies to      overeating is truly used to cope with emotional
their own situation, and receive group sup-         upsets, then the connection between each pre-
port (Ciliska, 1998).                               cipitating event and eating must be explored to
   If no group is available, the mental health      help the client find a more productive way of
practitioner may certainly share this informa-      responding.
tion with individual clients. When working             Finally, a few other things to consider:
with an individual, the delivery of the infor-
mation is paced to address the specific con-        • A referral can be made to a dietitian who
cerns of that client. Time is allowed for             agrees with a size acceptance philosophy
discussion of the client’s reactions to the in-       for help with the problem eating.
formation and for therapeutic input from the        • A consultation with a physical therapist or
practitioner.                                         exercise physiologist might be useful to the
   If the client’s eating pattern is in the nor-      person who has physical problems that in-
mal range, this assessment should be shared           terfere with becoming physically active.
with the client. Clients may respond to this        • Sometimes, meetings that include the
news with mixed feelings of relief for not            client and family members or significant
being at fault for their size, and sadness be-        others may be useful for educating all in-
cause thinness has eluded them.                       volved and for helping clients communi-
   If the client’s eating pattern is problem-         cate their needs about food and weight
atic, intervention calls for some discussion of       issues to those who are closest to them.
how this individual might plan to schedule          • Contact with a support group or with a size
meals at regular intervals. The client needs to       acceptance organization can help clients
work toward knowing that food will be avail-          maintain self-acceptance and feel less iso-
able at regular intervals (e.g., breakfast,           lated. One helpful resource is the National
lunch, and dinner, or lunch, dinner, and              Association to Advance Fat Acceptance
evening snack) to stop overeating. Some of            (NAAFA—www.naafa.org).
the overeating may be an attempt to hoard
food before the next famine. Techniques such        References
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     cine, 314(4), 193 –198.




                    GUIDELINES FOR COUNSELING
        9           CLIENTS WITH HIV
                    SPECTRUM DISORDERS


                    Paula J. Britton




Over 800,000 AIDS cases have been reported               clients and their family and friends who
in the United States, and the numbers of per-            are impacted by this disease, including those
sons infected with HIV continue to rise (Cen-            who are newly diagnosed, those who are chal-
ters for Disease Control and Prevention                  lenged with multiple opportunistic infec-
[CDC], 1999). Counselors are needed to treat             tions, and those facing end-of-life issues. It
          9 • GUIDELINES FOR COUNSELING CLIENTS WITH HIV SPECTRUM DISORDERS                     61

thus becomes increasingly important for            quickly. These resistant forms of the virus
counselors to be aware of the unique issues        may then be transmitted to others who will
involved with persons living with HIV/AIDS         not respond to the drug treatments.
and to possess some conceptualizations and            In an infected person, the virus can be
tools with which they can effectively interface    found in body fluids, including blood, semen,
with their clients.                                vaginal and cervical secretions, and breast
                                                   milk. It is most often transmitted by direct ex-
                                                   posure to blood by certain acts of sexual in-
DEFINITIONS AND KEY CONCEPTS                       tercourse and by needle sharing. Although it
                                                   is possible for a woman to infect her fetus
HIV (Human Immunodeficiency Virus) is the          during gestation, birth, or nursing, the num-
retrovirus that causes AIDS. Infection with        bers of infection in this manner have de-
HIV leads to changes in the immune system          creased due to preventive treatments during
that can result in a cluster of symptoms recog-    pregnancy and birth.
nized as AIDS (Acquired Immunodeficiency Syn-
drome), a viral disease that impairs the body’s
ability to fight other diseases. Persons who
                                                   MULTICULTURAL ISSUES
test positive for HIV have the virus in their
system; however, they may or may not be
                                                   There is a disproportionate percentage of
symptomatic. As the disease progresses and
                                                   AIDS cases among people belonging to minor-
the immune system becomes further compro-
                                                   ity cultures, including drug use cultures,
mised, the HIV-positive person becomes more
                                                   racial and ethnic minorities (particularly
susceptible to certain unique opportunistic
                                                   African Americans and Latinos), women (es-
infections. To be diagnosed with AIDS, a person
                                                   pecially women of color), youth (the highest
must have a T-helper lymphocyte blood count
                                                   rate of transmission is among adolescents), gay
of less than 200 and have had one or more op-
                                                   and bisexual men, and people who are home-
portunistic infections. The infections often
                                                   less or mentally disabled. Of new cases of per-
can be treated, but there is no current cure for
                                                   sons with diagnosed HIV (not AIDS) reported
the underlying immune deficiency caused by
                                                   to the CDC in 1999, 32% were women, and 77%
HIV. The course of the illness can be unpre-
                                                   of these women were African Americans or
dictable; some persons progress from being
                                                   Latinas. Among men, African Americans and
HIV positive and asymptomatic to developing
                                                   Latinos accounted for 59% of the new cases
full-blown AIDS very quickly; others remain
                                                   (CDC, 1999).
asymptomatic indefinitely.
                                                      Counselors need to be informed about dif-
   Early intervention, referring to the identi-
                                                   ferent cultures and maintain a perspective
fication of people with HIV and procurement
                                                   that honors and respects diversity. Winiarski
of corresponding medical and psychological
                                                   (1997) has recommended that counselors
treatment, is encouraged. This has become es-
                                                   working with persons with HIV disease ex-
pecially salient since the newer class of drugs,
                                                   pand their skills and knowledge regarding dif-
protease inhibitors, used in combination with
                                                   ferent cultures, paying special attention to:
other drugs (e.g., AZT), has been found to
slow the progression of the disease signifi-
cantly. However, the new drug treatment,             Issues around stigmatization: People from op-
often referred to as a drug cocktail, has its        pressed groups frequently have difficulty
own set of complex issues (Britton, 2000).           trusting outsiders and institutions. Thus, it
HIV-positive people may be required to take          is important not to interpret problems with
many drugs on a rigid schedule and experi-           self-disclosure as resistance or avoidance.
ence debilitating side effects. Moreover, un-        Nontraditional healing methods: It is impor-
less prescriptions are adhered to strictly, the      tant to consider how the culture conceptu-
virus develops a resistance to the drugs very        alizes illness, death, and dying.
62      PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

     Views on counseling: Some cultures view         most 25-year-olds are not prepared to deal
     counseling as supportive, but others may be     with these issues but instead are facing ca-
     very uncomfortable discussing personal in-      reer and life-planning issues.
     formation with someone outside the family
     or church.
                                                   COUNSELING AND HIV TESTING


UNIQUE ISSUES RELATED TO HIV/AIDS                  Testing for HIV has become a complicated
                                                   issue. Although there has been a push for
Although many of the issues that clients im-       early identification of people with HIV based
pacted by HIV/AIDS deal with are similar to        on medical advances, there are psychosocial
those of people with other chronic illnesses,      complexities around testing. There is real po-
there are some unique variables that set           tential for discrimination in finding out one’s
HIV/AIDS apart from other diseases:                HIV status, such as denial of insurance, hous-
                                                   ing, and employment.
1. Stigma. As HIV/AIDS has disproportion-
   ately impacted socially stigmatized popu-
                                                   Things to Know about HIV Antibody Testing
   lations and its transmission involves
   stigmatized activities (sexual activity and     The HIV antibody tests are very accurate.
   drug use), people with HIV disease are          They determine whether antibodies are pres-
   often perceived negatively.                     ent in the bloodstream; however, they do not
2. Unpredictability. With most other diseases,     make a diagnosis of AIDS. The two most com-
   there is a somewhat predictable course of       mon tests are the preliminary screening test,
   the disease, and people are given informa-      ELISA (enzyme linked immunosorbent assay),
   tion as to what to expect at certain stages.    and the confirmatory test, Western Blot.
   However, with AIDS, people have little             Home testing kits are now available; how-
   guidance as to what to expect, often vacil-     ever, they are more accurately described as at-
   lating from wellness to illness. Subse-         home collection kits. They have made testing
   quently, they can make decisions such as        more accessible to people in rural communi-
   leaving their job, selling their home, and      ties, but raise concern regarding the adequacy
   preparing for death, only to find themselves    of posttest counseling. Rapid tests, available
   feeling healthy again. This unpredictability    at some labs, allow for results in 5 to 30 min-
   has been compared to a roller-coaster ride,     utes; however, a major drawback of this type
   with emotions fluctuating from despair to       of testing is the higher rate of false positives
   hope and back again to despair. As a result,    until confirmatory tests are administered.
   clients report chronic apprehension and a          Testing can be confidential or anonymous.
   feeling of being out of control.                Confidential testing is similar to other med-
3. Isolation. Due to the nature of transmis-       ical tests and accessible within certain limita-
   sion, HIV can be an isolating disease. Peo-     tions. Anonymous testing is done without use
   ple frequently struggle with maintaining        of names or identifiable information and is in-
   healthy sexual and intimate relationships       accessible to anyone but the recipient. Many
   and as a result may end up feeling in-          who get tested do not return for results. In
   tensely alone.                                  most settings, pre- and postcounseling ac-
4. Age and Stage Differences. HIV/AIDS tends       company testing.
   to infect younger people who are being
   asked to deal with developmental concerns
                                                   Counseling Issues Associated with Testing
   that most often do not impact people until
   they are in their later stages of life. It is   Counselors can play a very salient role around
   common for a 75-year-old person to be deal-     testing issues. Common counseling themes
   ing with end-of-life planning; however,         include:
           9 • GUIDELINES FOR COUNSELING CLIENTS WITH HIV SPECTRUM DISORDERS                      63

   Dealing with feelings about being tested          tion, as a person in crisis usually cannot
   (e.g., ambivalence, fear).                        clearly process new information. However, it
   Supporting clients while they wait for            may be one of the few times a person with
   results.                                          HIV disease has access to counseling (e.g.,
                                                     posttest counseling), so it can be helpful to
   Education about HIV/AIDS.
                                                     provide persons with information that they
   Dealing with results of test and acute dis-       can refer to later (such as written material or
   tress that may result.                            pamphlets). It is also not the best time for a
                                                     psychological assessment. The client’s acute
                                                     reaction may not reflect premorbid diagnosis
DEVELOPMENTAL MODEL OF TREATMENT                     but a natural reaction to crisis. Instead, a
                                                     counselor should provide support, resources,
This model is based on several development           and a calming presence.
models, including readiness models (e.g., Pro-
chaska, DiClemente, & Norcross, 1992) and            Stage 2: Adjustment
crisis models (e.g., Nichols, 1985). The model’s
central idea is that AIDS is a disease of adjust-    Although acute distress is almost universal at
ment and change. Thus, certain counseling in-        beginning stages of HIV/AIDS, it usually de-
terventions may be more effective than others        creases after a few weeks. The next phase in-
during different phases of adjustment. (The          volves digesting the information about oneself
model serves only as a guide; the unique needs       and finding ways to handle it. The tasks involve
of each client will interface with the efficacy of   making some decisions about work and living
any intervention.)                                   arrangements as well as personal relationships.
                                                        As in phase 1, this process is unique for
                                                     each individual. Some people do not experi-
Stage 1: Crisis                                      ence any emotional problems during the
When first discovering their HIV status, most        asympotmatic phases of HIV disease. Others
infected people will experience acute dis-           remain in denial, which can be a necessary
tress; however, their reaction to the crisis is a    and beneficial means of coping. However, de-
unique process. Many report depression, anx-         nial that persists for extended periods of time
iety, and preoccupation with illness, includ-        can delay the onset of medical treatment and
ing intense fatalism or the belief that they         may have deleterious health effects.
will die soon. Denial is another common ini-            Stage 2 is often characterized by a decrease
tial reaction characterized by a description of      in denial. Instead, people may be faced with a
feeling “nothing” or “numb.” Many present            vacillation of denial with acute symptoms. It is
with symptoms of an adjustment disorder;             also a time of high risk for substance abuse
however, people can have other reactions that        and suicide.
are within the range of “normal.”                    Disclosure Issues. A common theme during
   At this stage, the counselor’s task is to pro-    this stage involves issues around who and
vide crisis intervention and supportive coun-        how to tell about one’s HIV status. Coun-
seling to facilitate coping. It is helpful to        selors need to be cognizant of and sensitive to
normalize clients’ responses and assist them         the dilemmas around disclosure, including
in managing their emotional reactions. This          potential for prejudice, challenges to sexual
may include assessing support networks and           and intimate relationships, being labeled an
making referrals, such as pastoral counseling,       unfit parent, vulnerability to violence, loss of
Alcoholics Anonymous, legal guidance, med-           job and insurance, and disclosure of sexual
ical/dental health care, testing sites, gay com-     orientation or past drug behavior. The coun-
munity resources, and methadone clinics.             seling relationship is a helpful place for
   This is not the time to delve into emotional      clients to explore disclosure issues and subse-
responses, nor is it the best time for educa-        quently be more planful and prepared.
64     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

Issues around Medical Treatment. As people          Stage 3: Acceptance
more deeply acknowledge their HIV status or
                                                    During this phase, people begin to form a
when confronted with their first HIV symp-
                                                    new sense of equilibrium: the formation of a
toms, they are often faced with difficult med-
                                                    new, more stable identity. Clients begin to ac-
ical decisions. Many are encouraged to take
                                                    cept their limitations but still manage their
medications early, often prior to any symp-
                                                    lives. They may talk about living with AIDS
toms. The strategy is a challenge because of
                                                    versus dying from AIDS.
the potential for side effects. Issues of compli-
                                                       Interpersonal and insight therapy is appro-
ance and adherence are critical. Counseling
                                                    priate at this stage and may involve a multi-
can assist clients in processing and making
                                                    tude of themes, including:
decisions around their medical care, includ-
ing helping people:                                 • Family of origin work.
                                                    • Establishing emotional, physical, and sex-
• Take responsibility for their own health.           ual contact with others.
• Observe and report symptoms to physician.         • Boundary development and setting healthy
• Develop partnerships with physicians.               limits.
• Comply with treatment.                            • Coming-out issues.
• Understand and keep track of medications.         • Self-awareness and attending to one’s own
• Prepare for and utilize medical appoint-            experiences.
  ments.                                            • Exploration of meanings and purpose.
• Become good consumers of treatment.               • Communication work.
• Assert rights.                                    • Spiritual exploration (e.g., finding appreci-
                                                      ation for small pleasures, a capacity to live
Suicide. People with HIV infection have               life in the present and to its fullest, focus-
higher levels of suicidal ideation and more           ing on quality versus quantity of life).
frequent attempts when compared with their
non-HIV-infected counterparts. Risk of sui-         Diagnosing Depression and Anxiety. During this
cide appears higher in people relatively early      phase, psychological assessments are indi-
on in the HIV disease (Marzuk et al., 1997).        cated. However, assessment is complicated be-
Unique correlations to suicidal ideation in         cause of the overlapping symptoms of HIV
persons with HIV disease include: onset of          disease with depression/anxiety. Thus, char-
symptoms, number of close friends diag-             acteristics of HIV disease should be taken into
nosed with HIV, knowing someone who died            account and diagnosis made after considering
from AIDS, and perceived risk of developing         overlapping symptoms, including symptoms of
AIDS.                                               AIDS-related infections, other illnesses, side
Counseling Interventions. A counselor’s role        effects of medications, and symptoms of dis-
during this stage is to provide ongoing and un-     tress. For example, symptoms often associated
conditional support. Counselors should con-         with anxiety or depression, such as problems
tinue to accept the affective experiences of        concentrating and making decisions, difficul-
clients, normalizing their range of feelings,       ties in social or occupational functioning, neg-
such as fear, anxiety, depression, and pleasure.    ative changes in physical appearance, fatigue
This is a good time to refer clients for group      and sleep disturbances, loss of appetite, de-
work, as groups can provide identification and      clining sexual interest, and weight loss, can be
expression of feelings, social involvement, se-     associated with HIV disease, especially if
curity in the continuity and structure of a         the neurological system has been impacted by
group, safety, modeling of adaptation to dis-       the disease.
ease, opportunity for touch, new perspectives,      Employment Issues. Persons with HIV often are
and education (e.g., medical information, de-       faced with difficult employment decisions.
railing myths).                                     Many rely on their employment for their health
          9 • GUIDELINES FOR COUNSELING CLIENTS WITH HIV SPECTRUM DISORDERS                               65

insurance. Often, they feel too ill to work and      dementia surfacing in otherwise healthy indi-
choose to go on disability. This option may          viduals. Counseling can be a forum for clients
offer them time to boost their immune system,        to process their fears and learn adaptive tech-
but conversely, it also is recognition that HIV      niques when faced with early symptoms. With
has gained control of their lives, which is espe-    the onset of late-stage dementia, more compli-
cially difficult for those strongly tied to their    cated caregiving issues surface, and family
careers. Moreover, with the success of new drug      and friends frequently need assistance in deal-
treatments, many who feel ready to return to         ing with their feelings and making appropriate
work fear losing their disability benefits.          caretaking plans.
                                                     Multiple Bereavement. Given that HIV is prin-
                                                     cipally spread through sexual behavior and
Stage 4: End-of-Life Issues
                                                     needle sharing, people with HIV infection
During this stage, clients are interested in         often experience multiple losses because of
talking about end-of-life concerns. These may        the prevalence of HIV in their social networks
include making decisions regarding final             (Neugebauer et al., 1992). As a result, people
medical treatment, estate planning and wills,        may experience bereavement overload, a syn-
dealing with unresolved relationships and            drome that occurs when a person has not
saying goodbye, making video/audiotapes or           completed the process of mourning the loss of
journals, discussing spiritual questions, plan-      one person when another dies. The pervasive,
ning for their funeral, and making rational          unrelenting feelings of sorrow, loss, and
suicide plans.                                       abandonment can be overwhelming.
    Clients may or may not be ill when they de-
sire to process these issues. The counselor
needs to be able to tolerate his or her own anxi-    SUMMARY
ety about death and dying and monitor per-
sonal beliefs and values around end-of-life          Although this model was presented as linear,
decisions. This can be particularly salient while    a spiral more accurately reflects it. Due to the
dealing with the issue of rational suicide, the      frequent and many losses and crises associ-
decision to rationally end one’s life to avoid the   ated with HIV, persons will frequently return
protracted pain, dependence, and economic de-        to earlier stages of adjustment (e.g., after a re-
cline associated with advanced HIV disease           cent death of someone with AIDS, during
(Werth, 1996). As there has been debate sur-         acute relational conflicts, when symptoms
rounding the role of mental health practitioners     begin or change, around appointments with
around hastened death requests, counselors are       physicians, or after episodes of discrimina-
encouraged to be familiar with the professional      tion). The process of adjustment and adapta-
literature regarding this controversial area (Sil-   tion is ongoing and frequently laborious.
verman, 2000; Rogers & Britton, 1994; Werth,            In counseling persons with HIV disease,
1992; Werth & Holdwick, 2000).                       counselors need to be cognizant of many
                                                     unique and challenging issues, as well as dis-
AIDS Dementia. HIV brain infection and
                                                     play sensitivity to multicultural issues. It also
AIDS-related opportunistic infections of the
                                                     requires a monitoring and management of the
central nervous system are some of the most
                                                     counselor’s own reaction to the often difficult
feared health problems for persons with HIV
                                                     issues. Using a developmental model can guide
disease. Significant deterioration in cognitive
                                                     counselors in choosing effective and appropri-
abilities can occur prior to systemic illness;
                                                     ate interventions.
however, these neurological deficits most often
coexist with other opportunistic infections.
Unfortunately, the protease inhibitors are not       References
successful in slowing neurological impair-           Britton, P.J. (2000). Staying on the roller coaster with
ment, and thus there are more cases of AIDS               clients: Implications of the new HIV/AIDS
66     PART I • COUNSELING FOR ADJUSTMENT DISORDERS AND LIFE STRESS

     medical treat ments for counseling. Journal of     Werth, J.L., Jr. (1996). Rational suicide? Implications
     Mental Health Counseling, 22, 85 –94.                  for mental health professionals. Bristol, PA: Taylor
Centers for Disease Control and Prevention.                 & Francis.
     (1999). HIV/AIDS surveillance report, 11(no. 2).   Werth, J.L., Jr., & Holdwick, D.J., Jr. (2000). A
Marzuk, P.M., Tardiff, K., Leon, A., Hirsch, C.,            primer on rational suicide and other forms of
     Hartwell, N., Portera, L., & Iqbal, M. (1997).         hastened death. The Counseling Psychologist,
     HIV seroprevalence among suicide victims in            28, 511–539.
     New York City, 1991–1993. American Journal of      Winiarski, M.G. (1997). HIV mental health for the
     Psychiatry, 154, 1720–1725.                            21st century. New York: New York University
Neugebauer, R., Rabkin, J., Williams, J., Remien,           Press.
     R., Goetz, R., & Gorman, J. (1992). Bereave-
     ment reactions among homosexual men expe-
                                                        Suggested Reading
     riencing multiple losses in the AIDS
     epidemic. American Journal of Psychiatry, 149,     Hoffman, M.A. (1996). Counseling clients with HIV
     1374 –1379.                                             disease: Assessment, intervention, and prevention.
Nichols, S.E. (1985). Psychosocial reactions of per-         New York: Guilford Press.
     sons with the acquired immunodeficiency            Kain, C.D. (1996). Positive: HIV affirmative counsel-
     syndrome. Annals of Internal Medicine, 103,             ing. Alexandria, VA: American Counseling
     765 –767.                                               Association.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C.     Kalichman, S.C. (1998). Understanding AIDS: Ad-
     (1992). In search of how people change. Ameri-          vances in research and treatment (2nd ed.).
     can Psychologist, 47, 1102–1114.                        Washington, DC: American Psychological As-
Rogers, J., & Britton, P. (1994). AIDS and rational          sociation.
     suicide: A counseling psychology perspective       Kelly, J.A. (1995). Changing HIV risk behavior: Practi-
     or a slide on the slippery slope. The Counseling        cal strategies. New York: Guilford Press.
     Psychologist, 22, 171–178.                         Odets, W., & Shernoff, M. (1994). The second decade
Silverman, M.M. (2000). Rational suicide, hastened           of AIDS: A mental health practice handbook. New
     death, and self-destructive behaviors. The              York: Haterleigh Press.
     Counseling Psychologist, 28, 540–550.              Rabkin, J., Remiem, R., & Wilson, C. (1994). Good
Werth, J.L., Jr. (1992). Rational suicide and AIDS:          doctors, good patients: Partners in HIV treatment.
     Considerations for the psychologist. The Coun-          New York: NCM.
     seling Psychologist, 20, 645 –659.
                 1 • WELFEL UNPAGED GALLEYS   67




PART II
Diagnosis and Treatment of
Adults with Mental and
Emotional Disorders
                 EFFECTIVE USE OF THE DSM
     10          FROM A DEVELOPMENTAL/
                 WELLNESS PERSPECTIVE


                 Earl J. Ginter and Ann Glauser



The authors of this chapter identify with the           the diagnostic information was applied after
developmental/wellness paradigm tradition-              diagnosis (Ginter, 1999). Effective use of the
ally associated with counseling (Ginter,                DSM depends on an understanding of that
1999). In this chapter, we review a number of           system, skill in applying it, and the develop-
diagnostic issues (e.g., cultural factors and           ment of a treatment approach that both recog-
the axis system) related to effective use of the        nizes the current role of the DSM in practice
Diagnostic and Statistical Manual of Mental Dis-        and is congruent with the defining features of
orders, fourth edition, text revision (DSM-IV-          counseling (Ginter, 1999).
TR) (APA, 2000). The chapter concludes by                   Hohenshil (1996) argues in favor of DSM di-
providing a review of two models (i.e., Ginter,         agnosis and presents several points to support
1999; Ivey & Ivey, 1998) that will assist any           his position. Two of his arguments deserve
mental health professional interested in                mention in this chapter. First, Hohenshil has
adopting and applying a developmental/well-             indicated that “diagnosis is not a process that
ness approach to therapy.                               occurs at a fixed point in time during the
                                                        counseling process, nor is it a static concept”
                                                        (p. 65) and, second, that diagnosis is not con-
THE DSM AND ITS ROLE IN TREATMENT                       fined to just one stage of the counseling pro-
                                                        cess but permeates the entire process from
Hohenshil (1996) indicated that a segment of            beginning to end and makes a unique contri-
counselors hold a negative perception of diag-          bution at each stage. Finally, Hohenshil asserts
nosis because they see diagnosis as either un-          that the antidiagnostic position found to linger
necessary or, at its worst, as a contraindicated        in counseling is aligned with the following be-
labeling process that hinders the full effec-           liefs: Counselors work with less severe client
tiveness of counseling—a process that can               problems than those that elicit a DSM diagnos-
even psychologically damage some clients. In            tic label; the unique developmental emphasis
truth, there are cases where diagnosis has              found in counseling results in counselors
proven to be of little value, and there are             focusing on issues of “normality” and “well-
other cases where it has resulted in harm to            ness” rather than the type of pathology identi-
the recipient of the diagnosis, but to a large          fied via the DSM; and specific counseling
degree, such outcomes reside less with the              models (i.e., client-centered, humanistic, and
process of diagnosis itself and more with how           family systems) espouse certain types of

                                                   69
70     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

client-counselor relationships that do not ne-      journey of sorts that has not reached its final
cessitate DSM diagnosis. Whether one agrees         destination. Diagnosticians should remember
or disagrees with Hohenshil’s position, the         that the DSM will always be anchored to the
prevailing reality of what constitutes contem-      cultural-time period marked by its publica-
porary counseling practice places those coun-       tion date and as such will continue to provide
selors who reject the role played by DSM            an incomplete understanding (or a complete
diagnosis in a tenuous position that they will      cultural appreciation) of mental disorders.
find increasingly difficult to defend.                 Providing a brief history of what had led up
    Ignorance of the DSM system is not con-         to the fourth edition (APA, 1994, 2000) enables
gruent with current expectations concerning         its users to better identify the strengths and
counseling practice. Even those counselors          weaknesses possessed by the newest edition.
not traditionally associated with reliance on       As indicated in the 2000 edition of the DSM,
DSM language cannot afford to be ignorant of        various nomenclatures used throughout the
it if they hope to maintain a certain level of      ages have relied to differing degrees on “phe-
professionalism and effectiveness. For exam-        nomenology, etiology, and course” (p. xxiv) to
ple, elementary school counselors who pos-          define and isolate the appropriate diagnosis.
sess knowledge of the DSM are better able to        The DSM system itself is just one of many
collaborate with other professionals and to         historical documents that offered a technical
make effective referrals that are consistent        language intended to convey a packet of infor-
with relevant ethical considerations. Finally,      mation to better understand the thoughts and
evidence for the pivotal role this diagnostic       behaviors of others. Even a cursory examina-
system has acquired in counseling was re-           tion of the various systems developed during
vealed in a 1990s survey in which counselors        different time periods reveals considerable
reported that the DSM served as the “most           variation in complexity. Some systems pro-
frequently used” resource to obtain informa-        vided relatively short (e.g., “handful”) diag-
tion related to practice (Hohenshil, 1994).         nostic listings; other systems provide long
This finding agrees with Seligman’s (1999) as-      (e.g., “thousands”) diagnostic listings, listings
sessment of the number of counselor training        that have been used for a multitude of reasons
programs that devote attention to teaching          (APA, 2000). Beginning in the first half of the
use of the DSM. What follows is an overview         1800s and leading up to the fourth edition of
of the DSM system that concludes with a brief       DSM, several events (APA, 2000, p. xxv–xxvi)
discussion of how it can be used in a manner        serve as important markers that contribute to a
consistent with the developmental perspec-          fuller appreciation of the details contained in
tive that is unique to counseling.                  the DSM-IV-TR:

                                                    • The impetus for developing a classification
DSM-IV-TR: CONTRIBUTING PRECURSORS                    system can be traced to the 1840 U.S. census,
                                                      when information about mental disorders
The current and prior versions of the DSM             was collected via the category “idiocy/in-
represent a concise explanation of a special-         sanity.”
ized language that possesses its own set of         • The mental disorders category was ex-
rules to determine when to apply its nomen-           panded to seven “labels” by the 1880 census
clature. Implied in the full title of the book is     (i.e., dementia, dipsomania, epilepsy, mania,
the idea that its nomenclature represents a           melancholia, monomania, and paresis).
professional understanding of what delin-           • In 1917, three groups (American Medico-
eates a mental disorder, and with each edi-           Psychological Association, Bureau of the
tion we are provided a glimpse of what                Census, National Commission on Mental
constitutes the prevailing professional under-        Hygiene) combined efforts to collect statis-
standing of various mental disorders at dif-          tical data from mental hospitals.
ferent historical points in time. This              • The American Medico-Psychological Asso-
historical progression represents a diagnostic        ciation changed its name in 1921 to the
   10 • EFFECTIVE USE OF THE DSM FROM A DEVELOPMENTAL/WELLNESS PERSPECTIVE                   71

  American Psychiatric Association (APA).          approximately 300 pages longer than the
  APA and the New York Academy of Medi-            DSM-III-R (despite the DSM-IV’s better or-
  cine both contributed to the development         ganization and apparent effort at greater
  of a nomenclature that was printed in the        clarity, it does use medical terminology that
  first edition of the American Medical As-        may lack meaning for those without previ-
  sociation’s Standard Classified Nomenclature     ous knowledge). The general revision ap-
  of Disease.                                      proach adopted in creating the DSM-IV
• Nomenclature developed by the U.S. Army          resulted in many significant changes, espe-
  and the Veterans Administration (e.g., acute     cially in the area of disorders typically
  mental disturbances where onset of the con-      diagnosed in infancy, childhood, or adoles-
  dition was sudden and relatively short in        cence as well as other noteworthy changes
  duration and conditions where the mental         in the areas of Adjustment Disorders, Mood
  disturbance involved both psychological          Disorders, Substance-Related Disorders,
  and physiological factors that contributed       Anxiety Disorders, and Personality Disor-
  directly to behaviors and/or thoughts of         ders (Hohenshil, 1994).
  the patient) and the World Health Organi-            The result is “an optimal balance in the
  zation (primarily its publication of the In-     DSM-IV with respect to historical tradition
  ternational Classification of Diseases [ICD])    (as embodied in the DSM-III and the DSM-
  greatly influenced the first edition of the      III-R), compatibility with ICD-10, evidence
  Diagnostic and Statistical Manual: Mental Dis-   from reviews of the literature, analyses of
  orders. (Similarly, the creation of the DSM-     unpublished data sets, results of field tri-
  IV was largely motivated by the anticipated      als, and consensus of the field” (APA, 2000,
  publication of the tenth edition of the ICD;     p. xxviii). As one would expect and as is
  Hohenshil, 1992.)                                articulated by Hohenshil (1994), the DSM-
• Various editions of the DSM reflect shifts       IV “is considerably more sensitive to bias
  in the basic foundational issues that have       issues, more scientific, more logically or-
  professionally validated the nomenclature        ganized, and better written than any of its
  relied on in each edition. For example, the      four predecessors” (p. 105).
  term “reaction” used in the DSM-I was as-            Finally, “to bridge the span between the
  sociated with the particular psychobiologi-      DSM-IV and DSM-V” (APA, 2000, p. xxix)
  cal view advocated by Adolf Meyer that           the APA published the DSM-IV-TR, which
  mental disorders represented a patient’s         introduces a number of important changes.
  reaction to factors of a biological, social,     Although most of the descriptive para-
  and psychological nature. Subsequent edi-        graphs in the DSM-IV were not revised, the
  tions of the DSM were not only developed         current text revision does reflect new re-
  to coincide with changes in the ICD, but         search into schizophrenia, Asperger’s Dis-
  also were designed (and written) in a man-       order, and other conditions. Expanding
  ner to move away from a theory-inf luenced       knowledge of Asperger’s Disorder since
  diagnostic system (e.g., Freudian influ-         1994 necessitated a fairly extensive revi-
  ences found in the DSM II were largely ex-       sion for that section. Some of the diagnostic
  punged in subsequent editions) to a              criteria related to Personality Change Due
  system of classification that is “neutral        to General Medical Condition, Paraphilias,
  with respect to theories of etiology” (APA,      and Tic Disorders were also updated. The
  1994, p. xviii).                                 DSM-IV-TR represents an effort to update
                                                   the ninth revision, clinical modification of
     With each new edition (i.e., DSM-II to        the ICD (ICD-9-CM) codes used since 1994
  DSM-IV-TR), the aim has been to increase         that are found in the DSM (including Con-
  the exactness and thoroughness of the di-        duct Disorder, Dementia, and Somatoform
  agnostic categories based on all relevant        Disorders). Finally, changes were made to
  available information. For example, Ho-          include more up-to-date information about
  henshil (1994) reports that the DSM-IV is        age, culture, gender, course, associated
72      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

     features, and familial patterns of mental       regarding the misuse of labels, the type of di-
     disorders to be consistent with recent re-      agnostic label that is a central element to the
     search findings.                                system comprising the DSM’s categorical ap-
                                                     proach to mental disorders. The authors of
                                                     the DSM-IV-TR point out that users must
EFFECTIVE USE OF THE DSM: POINTS                     keep in mind that a particular mental disor-
OF CLARIFICATION                                     der is not the same for everyone placed in that
                                                     particular category. For example, although
The authors of the DSM-IV-TR are careful to          certain features of schizophrenia might place
clarify several aspects of the manual that are       a large number of individuals into a particu-
both open to misunderstanding and are cru-           lar diagnostic category, a closer inspection of
cial determinants of effective use. Specifi-         this group would reveal an amazing amount
cally, the authors address the use of the term       of within-group variability and would lead
“mental disorder,” a categorical system of di-       to the realization that all individuals cannot
agnosis, and culture as a mediating diagnostic       be reduced to a single diagnostic label (a key
factor. Of these areas, culture as a factor in ef-   reason for relying on the multiaxial approach
fective diagnosis deserves special attention.        found in the DSM). In other words, it is sim-
   The label “mental disorder unfortunately im-      ply wrong to believe that in any diagnostic
plies a distinction between ‘mental’ disorders       group, clinical variability does not exist. To
and ‘physical’ disorders that is a reductionistic    deny such variability is to reduce the DSM
anachronism of mind/body dualism. A com-             system to a cookbook approach to diagnosis
pelling literature documents that there is much      that will inevitably introduce deleterious ef-
‘physical’ in ‘mental’ disorders and much            fects into treatment.
‘mental’ in ‘physical’ disorders” (APA, 2000,            Sometimes, the misuse of categorical infor-
p. xxx). The authors of the DSM-IV-TR further        mation is difficult to detect and has an almost
state that “each of the mental disorders is con-     invisible quality during the period it is mis-
ceptualized as a clinically significant behav-       used because of the dominant social climate.
ioral or psychological syndrome or pattern that      What may seem correct and ethical during one
occurs in an individual and that is associated       period in history is later identified as a form of
with present distress (e.g., a painful symptom)      “oppression” (Glauser & Bozarth, 2001). For
or disability (i.e., impairment in one or more       example, prior to emancipation of the slaves in
important areas of functioning) or with a sig-       America, “running away” from one’s abusive
nificantly increased risk of suffering death,        owner was considered a symptom of a mental
pain, disability, or an important loss of free-      illness (Ginter et al., 1996; Weisskopf-Joelson,
dom” (p. xxxi). Also, the position advocated in      1980). The authors of the DSM clearly indicate
the DSM is that counselors use specifiers when       that its nomenclature is to be applied in con-
evaluating the presence of symptoms, symp-           junction with a prudent combination of clini-
toms used to identify those particular charac-       cal judgment and cultural sensitivity that
teristics that coalesce in a defining pattern that   recognizes that client behaviors may be tied to
denotes a certain mental disorder’s occurrence.      specific cultural dynamics typical of a group
Symptoms are best viewed as falling along a          rather than to a symptom of a particular men-
continuum rather than existing in some fixed         tal disorder.
amount. Such gradation (i.e., mild, moderate,            Effective treatment planning can occur only
severe) of symptoms is an essential component        if the client is truly understood, and in many
of arriving at an accurate diagnosis and effec-      cases, a client can be understood only if the
tive treatment.                                      counselor rendering the diagnosis possesses
   Another caveat related to effective use is        cultural sensitivity. The DSM-IV-TR repre-
introduced early in the fourth edition of            sents a significant improvement over earlier
the DSM. This caveat is linked with the long-        editions in its incorporation of cultural consid-
standing criticism of the DSM system                 erations for the counselor to ponder before
   10 • EFFECTIVE USE OF THE DSM FROM A DEVELOPMENTAL/WELLNESS PERSPECTIVE                      73

rendering a diagnosis. It should also be noted        concerning whether anorexia nervosa is a
that several authors believe the developers of        Western culture-bound syndrome.)
the most recent edition of the DSM did not go      3. Outline for Cultural Formulation. Although
far enough in weaving all the available multi-        criticized for being relegated to the ap-
cultural information needed into the DSM’s            pendix, the outline for evaluating cultural
diagnostic framework of guidelines.                   factors is considered by Smart and Smart
   Ivey and Ivey (1998) and others (e.g., Smart       (1997) as “essential and marks an impor-
& Smart, 1997) have been very critical of the         tant step forward in the cultural sensitiv-
DSM’s efforts to incorporate cultural sensi-          ity of the” DSM (p. 395). We also believe
tivity into its diagnostic scheme. Smart and          the outline offers a ready-made means to
Smart provide a critical but balanced review          systematically consider a host of factors
of the DSM’s shortcomings and strengths as            related to culture. These include cultural
they pertain to five areas:                           identity, cultural explanations for an ill-
                                                      ness, contributing psychosocial factors,
1. Cultural-Specific Sections. Seventy-nine of        level of functioning, and the client-coun-
   the 400 DSM-IV disorders provide specific          selor relationship.
   cultural information. This inclusion repre-     4. Culturally Sensitive Changes on Axis IV. The
   sents a vast improvement over earlier edi-         focus of this axis is psychosocial and other
   tions, but an assessment of the scope              forms of stress, and Smart and Smart
   devoted to each section reveals an incon-          (1997) point out that in their view, the
   sistent approach in terms of the depth of          changes appearing in the DSM, “although
   coverage. The inconsistency is evident in          minor, do in fact, broaden the concept of
   that in some cases only a few words are            psychosocial-environmental influence and
   used as cultural qualifiers, while in other        make Axis IV more sensitive to issues
   cases the text devoted to a disorder covers        likely to be presented by minorities”
   several paragraphs.                                (p. 395). When used as part of the diagno-
2. Glossary of Culture-Bound Syndromes.               sis, Axis IV results in a better understand-
   Twenty-five syndromes are reported in an           ing of the diagnostic value of considering
   appendix and are described in the DSM              discrimination, migration, assimilation,
   as “locality-specific troubling experiences        and acculturation as potentially defining
   that are limited to certain societies or cul-      features of a client’s life.
   tural areas” (Smart & Smart, 1997, p. 394).     5. Addition of Culturally Sensitive V Codes.
   The means of reporting this information            Smart and Smart (1997) call attention to
   has received somewhat heated criticism and         “acculturation problems” and “religious or
   has been referred to by Smart and Smart as         spiritual problems” found in the V Codes
   a sort of “tourist” approach to reviewing a        and suggest that such additions represent
   very important area of consideration. Fur-         an improvement over the DSM-III. Accul-
   thermore, Smart and Smart suggest a West-          turation is listed in the V Codes in a man-
   ern cultural bias exists that results in           ner to help the counselor consider the
   Western cultural-bound categories being            degree of impact of cultural adjustment on
   treated differently from those listed in this      client symptoms. Also, according to Smart
   appendix. The result of the differential           and Smart, the structure provided “leaves
   treatment is an inconsistent formatting            the counselor great latitude in deciding
   used in the DSM. For example, Smart and            how to diagnose this issue” (p. 396). Simi-
   Smart argue there is reason to believe             larly, the means by which a client’s spiritu-
   anorexia nervosa represents a Western              ality is viewed reflects the greater cultural
   culture-bound syndrome and, as with any            sensitivity found in the DSM-IV-TR. Com-
   other culture-bound syndrome, deserves to          pared to DSM-III-R, which consistently
   be listed with the other 25 found in the           tied religion to psychopathology, the DSM-
   glossary. (Currently, there is no consensus        IV recognizes the positive role that religion
74      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

     can play in one’s life and allows the coun-   existence (Fong, 1995). Also, if relevant to di-
     selor to view this central concern as “de-    agnosis (and treatment), any repetitive pat-
     tached from other mental disorders as the     tern that relies on a defense mechanism that is
     case may warrant” (Smart & Smart, 1997,       believed to interfere with a person’s level of
     p. 396). For example, a Tibetan Buddhist      environmental adjustment is also noted on
     going for a long walk on a well-established   Axis II. Defense mechanisms are defined as
     pathway might be observed to stop and pick    “Automatic psychological processes that pro-
     up every earthworm encountered on the         tect the individual against anxiety and from
     heavily traveled pathway, carefully placing   awareness of internal and external dangers or
     each earthworm a safe distance away from      stressors” (APA, 2000, p. 807). Factors such as
     the path. This behavior might appear to one   inflexibility, intensity, and the environmental
     unfamiliar with the Tibetan form of Bud-      situation that fixes the meaning of defense
     dhism as an unusual form of excessive com-    mechanisms must be considered when noting
     pulsive behavior rather than a devotion to    reliance on defense mechanisms. In addition,
     respecting all reincarnated life forms and    other personality features that fail to meet
     protecting the myriad life forms that in-     the criteria for an established Personality Dis-
     habit earth from harm, injury, or death.      order can be noted here (Hohenshil, 1994).


                                                   Axis III: General Medical Conditions
THE AXIS SYSTEM
                                                   These conditions can be very relevant for both
The axial approach used in the DSM results in      treatment and prognosis, especially in terms
isolating the most pertinent information in dif-   of pharmacotherapy. Also, it is important to
ferent domains or information (Fong, 1995).        note that if a mental disorder is the result of a
                                                   medical condition, this will be indicated on
                                                   both Axes III and I (e.g., a mood disorder due
Axis I: Clinical Disorders
                                                   to hypothyroidism).
These are typically the presenting problems
and include disorders of the following types:
                                                   Axis IV: Psychosocial and Environmental
Anxiety Disorders; Disorders Usually First
                                                   Circumstances
Diagnosed in Infancy, Childhood, or Adoles-
cence; Delirium, Dementia, and Amnestic and        These include economic issues, education,
Other Cognitive Disorders; Mood Disorders;         health care services, housing, legal system/
and Substance-Related Disorders. Axis I also is    victim of crime, occupation, social environ-
used to report “other conditions that may be a     ment, primary support group (familial), and
focus of clinical attention.” Most clients seek    other environmental problems (e.g., natural
or are referred for counseling due to an Axis I    disasters, war, discord with a mental health
or a V-Code problem (Fong, 1995).                  professional or agency).


Axis II: Personality Disorders and                 Axis V: Global Assessment of Functioning
Mental Retardation                                 (GAF) Scale

When an Axis II diagnosis is the primary clin-     This scale addresses the dimensions of
ical concern, it is indicated by the qualifier     psychological, social, and occupational well-
“reason for visit” or “principal diagnosis.”       being and provides a score ranging from 0
Even though personality disorders are not al-      (inadequate information) to 100 (superior
ways initially apparent during a standard in-      functioning). The DSM-IV-TR provides infor-
take interview, their potential to disrupt an      mation about other assessments, specifically
otherwise effective treatment program re-          the Defensive Functioning Scale, the Global
quires the counselor to be sensitive to their      Assessment of Relational Functioning Scale,
   10 • EFFECTIVE USE OF THE DSM FROM A DEVELOPMENTAL/WELLNESS PERSPECTIVE                            75

which many family practitioners will find               developmental and etiological constructs, cul-
useful, and the Social and Occupational Func-           ture, helper role, causes for client’s complaint,
tioning Assessment Scale, which can be used             client’s family, and treatment. Of these, it is
to facilitate career counseling.                        the issue of pathology that Ivey and Ivey dis-
                                                        cuss at length. A condition that would be con-
                                                        sidered pathological when based only on a
EFFECTIVE PRACTICE AND THE DSM                          DSM perspective is represented by DCT as
                                                        a condition that is best viewed as a “logical
Nelson and Neufeldt (1996) capture the view             response to developmental history” (p. 336).
held by many practitioners concerning the               In their article, Ivey and Ivey explain
DSM’s use in actual practice when they write            how DCT’s treatment interventions are
that although the DSM “is necessary for pro-            organized around the types of information-
viding diagnosis-related information to third-          processing systems labeled sensorimotor, con-
party payers in terms of pathology, its primary         crete, formal, and dialectic/systemic. These
application in treatment planning is for the            information-processing systems allow effec-
identification of disorders such as depression          tive client-counselor communication to occur,
and psychosis that required psychotropic med-           and thus effective treatment. DCT not only of-
ication . . . [it] appears to have little utility for   fers a strongly rooted developmental system
actual selection of counseling strategies. Re-          of intervention but also offers the counselor a
search has shown that practitioners seldom use          means for reframing DSM “pathologizing”
it as a guide to counseling strategies because          terminology into positive terminology that
they do not find it useful. Thus . . . identifica-      better enables the client to build on latent de-
tion of ‘pathology’ is not necessarily useful in        velopmental strengths. For example, Ivey and
determining what kind of counseling interven-           Ivey list 11 personality styles (e.g., paranoid,
tions to pursue” (p. 609). The authors of the           antisocial, borderline, dependent) and review
DSM-IV-TR themselves indicate that it is not            each in terms of its positive aspect, the behav-
the intent of the DSM to serve as a ready-made          ior/thoughts that are likely to display them-
resource for recommended treatment.                     selves during a counseling session, probable
    We believe the DSM-IV-TR’s avoidance of             link to a particular family history, how the
the treatment arena is a strength, allowing             style is predicted to affect current relation-
counselors considerable flexibility in match-           ships outside of counseling, and a possible
ing a treatment approach to a particular dis-           treatment approach that will enable the client
order as long as the treatment approach is              to free latent strengths. For example, the posi-
supported empirically and with sound clinical           tive aspect of the dependent personality style
judgment. We also believe that it is possible to        is “We all need to depend on others.” In the
stay true to counseling’s unique defining fea-          early stages of counseling, the client can be ex-
ture of relying on a developmental perspective          pected to display “dependency on the thera-
in working with clients. (There are other               pist even outside of session and indecision,
defining features [Ginter, 1999], but the devel-        little sense of self.” The family history ob-
opmental aspect is widely recognized as a key           tained on such a client will probably reveal
feature.) Ivey and Ivey (1998) and Ginter (2001)        that family can be described as an “engulfing,
offer examples of such developmentally based            controlling family, [where the client is] not
approaches.                                             allowed to make decisions, [is] rewarded for in-
    Ivey and Ivey (1998) believe that Develop-          action, [and is] told what to do.” Current inter-
mental Counseling and Therapy (DCT)                     personal relationships for the client can be
bridges the gap between counseling’s unique             expected to reflect the following: “dependent
developmental perspective and the DSM diag-             on friends, drives people away with demands.”
nostic perspective. They contrast the way the           The probable treatment approach to adopt in
DSM and the DCT approaches view the issues              working with the dependent client, accord-
of locus of the client’s problem, pathology,            ing to Ivey and Ivey, involves the following:
76     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

“reward action, support efforts for self, use       assumption that all individuals described as
paradox, [and] assertiveness techniques” (see       having the same mental disorder are alike in
Ivey & Ivey, 1998, p. 338).                         all important ways” (p. xxxi). Thus, users are
    Ivey and Ivey’s (1998) DCT model is much        encouraged to gather supplemental informa-
more comprehensive than is evident in any           tion on each client to capture the complexities
brief review (e.g., they discuss how various        inherent in rendering a diagnosis. Simply
personality styles are related to Axis I diag-      stated, the DSM system can be an effective tool
noses) and deserves a more thorough study of        for counselors when they also keep in mind
its merits than is available in this chapter. An-   the following considerations:
other model that bridges the gap between DSM
diagnosis and counseling’s developmental ap-        • The DSM classifies mental disorders; it
proach is based on the work of George Gazda           does not classify people.
(Ginter, 1999). Ginter (2001) provides a review     • Diagnosis is an evolving process that oc-
of the theory and a case study to illustrate how      curs throughout each stage of the counsel-
a client with a DSM diagnosis of depression can       ing process.
be effectively worked with by utilizing the         • The DSM system possesses various limita-
Life-Skills Model (LSM) (Ginter, 1999). The           tions, and the users must be knowledge-
LSM is based on decades of theory building            able about these limitations.
based on empirical support. Following a DSM         • Effective treatment planning depends on
diagnosis, a client’s treatment plan is devel-        whether the client is fully understood, and
oped in relation to both the diagnosis and an         effective diagnosis always reflects careful
appropriate life-skills assessment (assessment        consideration of cultural contexts.
measures have been developed for children,          • Ignorance of the DSM system is incongru-
adolescents, adults, college students, and incar-     ent with current definitions of effective
cerated adolescents). LSM treatment is not only       counseling practice.
a developmentally dependent approach that           • A developmental approach to practice (e.g.,
recognizes the contributions of major develop-        DCT, LSM) can provide an effective bridge
mental theories but is an approach devoted            between use of the DSM system and the
specifically to exploring problems and arriving       theoretical foundation of counseling.
at solutions based on four all-encompassing
developmental dimensions (i.e., interpersonal       References
communication/human relations skills, prob-
                                                    American Psychiatric Association. (1994). Diagnos-
lem-solving/decision-making skills, physical
                                                        tic and statistical manual of mental disorders (4th
fitness/health maintenance skills, and identity
                                                        ed.). Washington, DC: Author.
development/purpose-in-life skills). Again, as      American Psychiatric Association. (2000). Diagnos-
with Ivey and Ivey, the reader is referred to           tic and statistical manual of mental disorders (4th
published works in this area to ascertain a             ed., text rev.). Washington, DC: Author.
more thorough description of the LSM.               Fong, M.L. (1995). Assessment and DSM-IV diag-
                                                        nosis of personality disorders: A primer for
                                                        counselors. Journal of Counseling & Develop-
SUMMARY                                                 ment, 73, 635 –639.
                                                    Ginter, E.J. (1999). David K. Brook’s contribution to
                                                        the developmentally based life-skills approach.
The authors of the DSM have aimed for greater
                                                        Journal of Mental Health Counseling, 21, 191–202.
thoroughness and clarity of presentation with
                                                    Ginter, E.J. (2001). Private practice: The profes-
each revision. The authors of the DSM-IV-TR
                                                        sional counselor. In D.C. Locke, J.E. Myers, &
(APA, 2000) acknowledge the heterogeneous               E.L. Herr (Eds.), The handbook of counseling
temperament of individuals within categories            (pp. 355 –372). Thousand Oaks, CA: Sage.
of mental disorders and the fact that diagnosis     Ginter, E.J., (Chair), Ellis, A., Guterman, J.T., Ivey,
is a “probabilistic” endeavor (p. xxxi). There          A.E., Locke, D.C., & Rigazio-DiGilio, S.A.
are no assumptions of absolute categories, “no          (1996, April). Ethical issues in the postmodern
                                            11 • CLINICAL AND DIAGNOSTIC INTERVIEWING                      77

     era. World conference of the American Coun-         Nelson, M.L., & Neufeldt, S.A. (1996). Building on
     seling Association, Panel discussion, Pitts-             an empirical foundation: Strategies to en-
     burgh, PA.                                               hance good practice. Journal of Counseling &
Glauser, A., & Bozarth, J.D. (2001). Person-cen-              Development, 74, 609–615.
     tered counseling: The culture within. Journal       Seligman, L. (1999). Twenty years of diagnosis and
     of Counseling & Development, 79, 142–147.                the DSM. Journal of Mental Health Counseling,
Hohenshil, T.H. (1992). DSM-IV progress report.               21, 229–239.
     Journal of Counseling & Development, 71, 249–251.   Smart, D.W., & Smart, J.F. (1997). DSM-IV and cul-
Hohenshil, T.H. (1994). DSM-IV: What ’s new. Jour-            turally sensitive diagnosis: Some observations
     nal of Counseling & Development, 73, 105 –107.           for counselors. Journal of Counseling & Develop-
Hohenshil, T.H. (1996). Editorial: Role of assess-            ment, 75, 392–398.
     ment and diagnosis in counseling. Journal of        Weisskopf-Joelson, E. (1980). Value: The infant ter-
     Counseling & Development, 75, 64 –67.                    rible of psychotherapy. Psychotherapy: Theory,
Ivey, A.E., & Ivey, M.B. (1998). Reframing DSM-IV:            Research and Practice, 17, 459– 466.
     Positive strategies from developmental coun-
     seling and therapy. Journal of Counseling & De-
     velopment, 76, 334 –350.




                    CLINICAL AND
      11            DIAGNOSTIC INTERVIEWING


                    Timothy M. Lane and Donna L. Fleming




Conducting a skillful diagnostic interview is            psychopathology, including clinical presenta-
a fundamental and essential tool for the men-            tion, prevalence, course, and treatment op-
tal health clinician. Diagnostic skills are in-          tions for the diagnostic categories; (4) the
dispensable in therapeutic relationships, as             ability to skillfully apply the diagnostic pro-
well as in forensic assessments and social sci-          cess; and (5) an awareness of the ethics, pit-
ence research. Furthermore, a major trend to-            falls, and limitations of the diagnostic
ward treatment or practice guidelines for                process. On the surface, the diagnostic pro-
specific diagnoses underscores the impor-                cess can appear deceptively simple, but
tance for every clinician to have well-devel-            human psychopathology is far from simple.
oped diagnostic skills. Expert clinical                  With over 200 DSM-IV diagnostic possibili-
interviewing requires the clinician to have (1)          ties, solid diagnostic skills are needed to serve
solid counseling and communication skills;               clients well. This chapter briefly reviews the
(2) a working knowledge of the Diagnostic and            basics of the clinical interview, the diagnostic
Statistical Manual of Mental Disorders, text revi-       process and components, the benefits of inter-
sion (DSM-IV-TR) (APA, 2000) diagnostic cri-             view tools, the limitations and pitfalls of the
teria; (3) empirically based knowledge of                diagnostic interview, and suggested readings.
78      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

OVERVIEW OF THE CLINICAL INTERVIEW                         vacy, adequate uninterrupted time, and free-
                                                           dom from distractions. The postinterview
The clinical interview is a focused, time-                 phase should allow time for tasks such as
efficient process typically consisting of a sin-           notes and reports, referrals, consultations,
gle 50-minute session. Occasionally, more                  and formulation of plans or questions for the
time or a second interview is required for                 next session.
complex cases. Empathy, warmth, and good
communication skills are foundations for a
                                                           Multidimensional Context of
smooth clinical interview and prevent it from
                                                           Human Functioning
becoming a cold, detached interrogation of
the client. The major components of the clini-             Clinicians need to be ever mindful of the mul-
cal interview usually consist of (1) warming               tidimensional context of behavior, thought,
up and building rapport, (2) screening for the             and emotion by utilizing a biopsychosocial or
problem with an empathic understanding of                  human ecology perspective (Millon & Davis,
the client’s pain, (3) gathering and integrat-             1999). Both current and historic factors may
ing the empirical database, (4) formulating a              affect behavior. Complex cultural, environ-
theoretical and diagnostic conceptualization,              mental, biological, genetic, personality, and
(5) giving feedback tailored to the client’s               developmental factors and interactions among
ability to understand it, and (6) determining              factors are but samples of the myriad compo-
prognosis and treatment recommendations. A                 nents that may contribute to human behavior.
more detailed summary of the clinical inter-               Readers are referred to Millon and Davis for
view components is listed in Table 11.1.                   further study of the current state of knowledge
   The interview may be tailored to each                   concerning the developmental influences on
client, setting, and situation. Clinicians must            the etiology of pathological conditions.
surmise the current state of the client so as to
fine-tune the interview for maximal effective-
ness (Hersen & Turner, 1994). The prepara-                 THE DIAGNOSTIC PROCESS
tion and postinterview follow-up components
of the interview are also important. Advanced              The diagnosis should be made in the most
preparations can enhance the efficiency, ef-               heuristic and parsimonious manner (Maxmen
fectiveness, and focus of the clinical inter-              & Ward, 1995). Amchin (1991) likened the di-
view. Preparations include review of referral              agnostic process to that of a funnel that is wide
information, intake forms, mental health or                open with diagnostic possibilities at the begin-
medical records, and assessment results. Ad-               ning of the process, but continually and sys-
ditionally, the clinician should ensure pri-               tematically narrows as information is found to
                                                           support or rule out diagnoses. The clinician
                                                           gathers, explores, and organizes information
TABLE 11.1 Components of the Clinical Interview            in ways that help first to identify the diagnos-
 1. Introductions, warmup, and screening for problems.     tic possibilities most consistent with the data
 2. Presenting problems and symptoms (with behavioral      and then to rule out the remainder of possibil-
    examples).
                                                           ities until a single parsimonious diagnostic
 3. Mental Status Exam (MSE) and level of functioning.
 4. History of the presenting problems.                    picture emerges (Othmer & Othmer, 1994). A
 5. Personal, medical, and psychiatric history (and        framework of logical steps can help make the
    family history as relevant).                           complexity manageable. Maxmen and Ward
 6. Biopsychosocial information (i.e., culture, race,      suggested the following steps in the diagnostic
    religion, social stressors).
                                                           process: (1) collect data, (2) identify the pathol-
 7. Differential diagnoses systematically considered
    and eliminated.                                        ogy (if present), (3) evaluate the reliability of
 8. Diagnoses most consistent with all data.               the data, (4) determine overall distinctive fea-
 9. Client feedback, questions, concerns, and prognosis.   tures of the symptom picture, (5) check diag-
10. Treat ment recommendation and treat ment               nostic DSM-IV criteria against the client’s
    agreement.
                                                           symptom picture, and (6) resolve diagnostic
                                        11 • CLINICAL AND DIAGNOSTIC INTERVIEWING                 79

uncertainty. For medical safety, prognostic,        that ranks highest for treatability, positive
and treatment reasons, eliminating possible         outcome and prognosis, and the least serious
disorders can be as important as identifying        pathology and social stigma (Morrison, 1995).
probable disorders.                                    The Principle of Percentages suggests that
   Appendix A of the DSM-IV is a com-               between two or more diagnostic options, con-
pendium of decision trees for differential di-      sideration is given to the diagnosis that is
agnoses that illustrate the specific criteria and   more frequently found in the population from
logic of the differential diagnostic process.       which the client is drawn (Morrison, 1995).
While DSM-IV generally requires specific be-           The Principle of the Best Data suggests that
havioral criteria, symptom duration and             the relative decision-making influence of the
severity, and certain temporal relationships        data should be based on the validity, reliabil-
among symptoms to be present in order to            ity, objectivity, and longitudinal nature of
make a diagnostic decision, the following pro-      that data.
cess is also necessary. All alternative explana-
tions for the symptoms and problems must
                                                    The Empirical Database
have been considered and ruled out before a
definitive diagnosis is achieved. Some diag-        Components of the empirical database include,
nostic rules can help organize and guide the        but are not limited to, presenting problems,
diagnostic decision-making process.                 history of those presenting problems, mental
                                                    status, mental health history, family mental
                                                    health history, personal and family medical
Diagnostic Rules
                                                    history, social history, educational and mili-
The Rule of Parsimony suggests that the clini-      tary history, work history, relationship and
cian seek the single most elegant, economical,      marital history, sexual history, alcohol and
and efficient diagnosis that accounts for all the   drug history, legal history, and leisure time ac-
available data. If a single diagnosis is insuffi-   tivities (Hersen & Turner, 1994). These areas
cient, seek the fewest number that best explain     can be addressed adequately in most inter-
the symptoms (Maxmen & Ward, 1995).                 views through the use of a flexible interview-
   The Rule of Diagnostic Hierarchy, as explained   ing approach. Some areas may not be relevant
by Morrison (1995), suggests that the most se-      to the clinical picture and may be eliminated
vere diagnoses that could account for the symp-     from further exploration by only one question;
toms must be ruled out in descending order.         others will need to be addressed in depth. The
The hierarchy declines in medical severity:         database can benefit from the additional objec-
medical or pharmacologic > psychotic > mood >       tive information from family members,
anxiety > somatic > sexual > personality > ad-      friends, police reports, medical or treatment
justment > no mental disorder (Maxmen &             records, and other sources.
Ward, 1995). Sudden clinically significant             The initial screening of the problem focuses
changes in cognition, mood, anxiety, or person-     on recent primary and secondary symptoms,
ality unexplained by environmental or social        symptom severity, temporal relationships
factors may be harbingers of undiagnosed med-       among data, client explanation of the problems,
ical or neurological problems and must be           client level of functioning (in family, social,
ruled out through an immediate referral to ap-      work, and education realms), and biopsychoso-
propriate medical specialists (i.e., primary care   cial factors affecting the client. All data are
physician, psychiatrist, or neurologist).           compared with the most applicable syndromes
   The Rule of Chronology suggests that the         for goodness of fit. More specificity and his-
disorder that is present the longest will tend      tory will help clarify the current and recent
to have priority if it can account for the cur-     clinical picture and symptom presentation.
rent symptoms (Morrison, 1995).                     The history of the presenting problem is a nat-
   The Rule of Safety applies when the former       ural extension of the initial screening of the
rules do not. When the diagnostic picture is        problem. It is important to remember to assess
unclear, the “safest” diagnosis is the diagnosis    three time periods in the client’s history—
80     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

premorbid (the period before any symptoms          of the mental status is examined in a stan-
are experienced), prodromal (the period from       dardized manner) is considered the safest op-
first symptom onset until clinical severity),      tion, as some problems (i.e., soft neurological
and syndromal (the period from which clinical      signs) are revealed only through systematic
severity of symptoms is first reached to the       testing. Some clinicians tailor the MSE to the
present)—as each may contain important clues.      particular client based on the overall data ob-
The history of the presenting problem should       tained from the interview and referral source.
describe the earliest onset of the current symp-      As with any single piece of information,
tom picture, with dates of onset, symptoms,        when used alone, the MSE is sorely insuffi-
and course, and note any temporal relationship     cient as a basis for making a diagnosis. The
between symptoms and other factors (i.e.,          MSE must be combined with a thorough and
stress, trauma, medical problems). Note recent     reliable examination of all current symptoms
changes in level of functioning, distress, and     and a history of all systems and symptoms to
insight. The empirical database information        arrive at a valid diagnostic formulation. In
must vary flexibly, led by the client’s symp-      fact, there are many diagnostic categories for
toms and clues. Thoroughness is an important       which the client will have a “normal” MSE.
quality of the interview because a single fact     The major components of the MSE include the
can change the entire diagnostic picture.          following (Othmer & Othmer, 1994):
   The remainder of the history is gathered
in as efficient a manner as possible. The his-     General observations:
tory should paint a longitudinal picture of         1. Appearance: self-care and hygiene: neat,
the client’s life in a cultural context. A             clean, disheveled, body odor; presentation:
complete personal history includes such                manner and appropriateness of clothing,
background as developmental history, edu-              odd or eccentric appearance; weight-to-
cational issues, major events, family dynam-           height ratio; nutritional cues; scars or
ics, social development, accomplishments,              markings; recent injury or signs of medical
strengths, and protective factors. The med-            problems.
ical and psychiatric history should specify         2. Reaction to the interviewer: friendly,
previous medical or psychiatric problems,              compliant, terse, argumentative, socially
care providers, treatments, medication trials          appropriate.
with specific dosages, outcomes, compliance,        3. Psychomotor behavior: peculiar manner-
and side effect problems. Familial history is          isms, extrapyramidal movement, nonverbal
important for both dynamic and develop-                symptoms of anxiety, observable energy
mental contexts as well as genetic vulnera-            level, pressured movements or immobility,
bilities. Clues to the current clinical picture,       odd posturing, grimacing, nonverbal signs
latent problems, prognosis, and most promis-           of hypervigilance.
ing treatment approaches can lie in any area        4. Energy level: normal, manic, lethargic/
of history.                                            depressed.

                                                   Cognitive and affective aspects:
MENTAL STATUS EXAM (MSE)                            5. Consciousness: responsiveness and aware-
                                                       ness, lethargic, stuporous, variable.
The MSE is at the heart of the diagnostic inter-    6. Attention and concentration: maintains
view and should capture the individual’s               and shifts attention fluidly, concentrates
immediate mental status at the time of the in-         and focuses on relevant stimuli.
terview. The MSE assesses a wide range of           7. Orientation: person, place, and time.
psychological and neurological functions. The       8. Memory: immediate, short-term, remote.
exam can range from a formal exam to a very         9. Speech: mute, pressured, speeding or
informal assessment, depending on many                 slow, loud, timid, shaky, unintelligible,
variables. A formal exam (where every aspect           fluency.
                                        11 • CLINICAL AND DIAGNOSTIC INTERVIEWING                   81

10. Content of thinking: delusions, hallucina-      Assessment tools such as objective tests,
    tions, illusions, anxious, obsessive, para-     symptom checklists, and structured inter-
    noid, suicidal, homicidal thoughts,             views can significantly enhance the empiri-
    somatic preoccupations.                         cal database with accurate and reliable
11. Process of thinking: abstract, concrete,        information. Assessment tools include per-
    linear, logical, flexible, tangential, speed-   sonality inventories such as the Minnesota
    ing, odd, ruminative, intrusive thoughts        Multiphasic Personality Inventory, second
    or thought insertion.                           edition (Butcher, Dahlstrom,Graham, Telle-
12. Mood and affect: flat, blunted, volatile,       gen, & Kaemmer, 1989), symptom measures
    hostile, incongruent, euthymic.                 such as the Beck Depression Inventory-II,
13. Intelligence: compare to best premorbid         (Beck, Steer, & Brown, 1996), and symptom
    level and note temporal changes.                checklists such as the Symptoms Checklist-
14. Executive functioning: decision making,         90-R (Derogatis, 1983). Neuropsychiatric
    organizing and planning ability (critical       tests, which include the Mini-International
    for self-care).                                 Neuropsychiatric         Inventory-2    (Sheehan
15. Insight and judgment: reflects insight          et al., 1998), are very useful and sometimes
    into current problems, use of good judg-        invaluable, but may require specific training
    ment by testing reactions to questions re-      and skills to administer and interpret. One de-
    quiring social and logical judgment.            tracting feature of some tools is that they may
                                                    take a significant amount of time to administer
   It is important for clinicians to commit to      or add considerable expense. Often, these are
memory the components and procedures of             administered after the first session, when a
conducting the MSE. Equally important is            clinician needs to gain more objective informa-
gaining the knowledge of what various results       tion. Structured interviews have significantly
to each MSE component might indicate in             increased the reliability (interrater, test-retest,
light of each syndrome or disorder. In some         and internal consistency) of the diagnostic in-
cases, the MSE may be used to monitor client        terview over that of the unstructured inter-
mental status from time to time and can be          view (Segal, 1997). There are structured
one measure of client change. Because time          interviews for virtually every Axis I and Axis
and efficiency are often issues, some clini-        II diagnostic category. A widely used struc-
cians opt to use a short form of the MSE inter-     tured interview for DSM-IV Axis I disorders is
view such as the Mini-Mental State Exam             the Structured Clinical Interview for DSM-IV
(Folstein, Folstein, & McHugh, 1975), with          (First, Spitzer, Gibbon, & Williams, 1995). For
good results. Whether the MSE is formal or in-      Axis-II, the Structured Clinical Interview for
formal, short or long, it is important that the     DSM-IV Axis II Personality Disorders (SCID-
interviewer be able to reliably determine the       II, Ver. 2.0) (First, Spitzer, Gibbon, Williams, &
MSE results after the diagnostic interview.         Lorna, 1994) is a prime example of a flexible
There are many excellent books currently            interview schedule that helps work through
available that give specific instruction on how     differential diagnoses.
to utilize the clinical interview and mental            Choice of assessment tools and structured
status exam in a diagnosis-specific manner.         interviews may depend on many variables,
Those works with which we are most familiar         such as the specific information desired by
are listed under Recommended Reading at the         the clinician, relative psychometric properties
end of the chapter.                                 of each instrument, time of administration,
                                                    ability of the client to participate in testing,
                                                    ease of scoring, specific training or educa-
DIAGNOSTIC TOOLS                                    tional background needed to administer or
                                                    interpret the findings, and the benefit-to-cost
The more complex the diagnostic scenario,           ratio. As with all tools, the cost- (time and ex-
the more important objective data become.           pense) to-benefit ratio must be considered.
82     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

One caution is given: Except as pure research      seem much more abundant in textbooks than
criteria or unless otherwise specified, these      in real-world practice, and there is no shortage
instruments should be used only as a supple-       of complex cases readily available to baffle
ment to the professional diagnostic interview,     even the most experienced clinician. The clini-
as most are not designed to be used alone as       cal interview is often the first step toward
the sole determinant of a diagnosis. These         helping clients who may have suffered a great
tools can be powerful additions to the clini-      deal. Therefore, the time and energy invested
cian’s diagnostic armament and are strongly        in developing sound clinical and diagnostic
recommended when used judiciously.                 skills will pay clinicians many dividends in
                                                   the empathic understanding of clients and in-
                                                   creasing clinical effectiveness.
LIMITATIONS AND PITFALLS IN THE
DIAGNOSTIC PROCESS                                 References

                                                   Amchin, J. (1991). Psychiatric diagnosis: A biopsy-
Some common problems we’ve observed in su-              chosocial approach using DSM-III-R. Washing-
pervision that may contribute to misdiag-               ton, DC: American Psychiatric Press.
noses include the following:                       American Psychiatric Association. (2000). Diagnos-
                                                        tic and statistical manual of mental disorders (4th
1. Failure to acknowledge one’s limitations:            ed., text rev.). Washington, DC: Author.
   Inevitably, some cases will be beyond one’s     Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck
   area of expertise, and ethics may mandate            Depression Inventory (2nd ed.). San Antonio,
   consultation, supervision, or a referral to          TX: Psychological Corporation.
                                                   Butcher, J.N., Dahlstrom, W.G., Graham, J.R., Telle-
   other experts in respective fields.
                                                        gen, A., & Kaemmer, B. (1989). Minnesota Mul-
2. Not recognizing the limitations of the data:
                                                        tiphasic Personality Inventory-2 (MMPI-2).
   Data must be valid, reliable, pertinent, ob-         Minneapolis: University of Minnesota Press.
   jective, and complete. A diagnosis is only      Derogatis, L.R. (1983). Symptom Check List 90–
   as good as the data on which it is based; in-        Revised Version, manual 1. Baltimore: Johns
   complete information will impact on diag-            Hopkins University School of Medicine.
   nostic accuracy.                                First, M.B., Spitzer, R.L., Gibbon, M., & Williams,
3. Jumping to conclusions: Intuition and first          J.B.W. (1995). Structured Clinical Interview:
   impressions, although helpful when devel-            For Axis I DSM-IV disorders–patient edition
   oping diagnostic hypotheses, are not objec-          (SCID-I/P, Ver. 2.0). New York: New York
   tive data and can lead to a dangerous                State Psychiatric Institute, Biometrics Re-
                                                        search Depart ment.
   process of taking evaluative shortcuts and
                                                   First, M.B., Spitzer, R.L., Gibbon, M., Williams,
   relying excessively on compromised data.
                                                        J.B.W., & Lorna, B. (1994). Structured Clinical
   A single important overlooked fact can               Interview for DSM-IV Axis II personality disor-
   lead to misdiagnosis.                                ders (SCID-II, Ver. 2.0). New York: New York
4. Stereotyping: Unsupported assumptions                State Psychiatric Institute, Biometrics Re-
   about race, culture, gender, age, and diag-          search Depart ment.
   nostic categories can lead to judgment          Folstein, M.F., Folstein, P.R., & McHugh, P.R.
   errors similar to those of jumping to conclu-        (1975). Mini-Mental State: A practical method
   sions. Great heterogeneity often exists              for grading the cognitive state of patients for
   among persons with the same diagnosis.               the clinician. Journal of Psychiatric Research,
                                                        12, 189–198.
                                                   Hersen, M., & Turner, S. (1994). The interviewing
                                                        process. In M. Hersen & S. Turner (Eds.), Di-
SUMMARY
                                                        agnostic interviewing. New York: Plenum Press.
                                                   Maxmen, J., & Ward, N. (1995). Essential psychopath-
A large number of clinical skills must be inte-         ology and its treatment: Second edition for DSM-
grated effectively for the clinical interview           IV. New York: Norton.
and diagnostic process to proceed smoothly.        Millon, T., & Davis, R.D. (1999). Developmental
“Textbook cases” of mental health problems              pathogenesis. In T. Millon, P.H. Blaney, & R.D.
                                                          12 • EFFECTIVE TREATMENT PLANNING                     83

    Davis (Eds.), Oxford textbook of psychopathology.       Hersen, M., & Turner, S. (Eds.). (1994). Diagnostic in-
    New York: Oxford University Press.                          terviewing (2nd ed.). New York: Plenum Press.
Morrison, J.R. (1995). The first interview: Revised for     Maxmen, J., & Ward, N. (1995). Essential psychopath-
    DSM-IV. New York: Guilford Press.                           ology and its treatment: Second edition for DSM-
Othmer, E., & Othmer, S. (1994). The clinical inter-            IV. New York: Norton.
    view using DSM-IV: Vol. 1: Fundamentals. Wash-          Morrison, J.R. (1995). The first interview: Revised for
    ington, DC: American Psychiatric Press.                     DSM-IV. New York: Guilford Press.
Segal, D.L. (1997). Structured interviewing and             Othmer, E., & Othmer, S. (1994). The clinical inter-
    DSM classification. In S. Turner & M. Hersen                view using DSM-IV: Vol. 1: Fundamentals. Wash-
    (Eds.), Adult psychopathology and diagnosis (3rd            ington, DC: American Psychiatric Press.
    ed.). New York: Wiley.                                  Othmer, E., & Othmer, S. (1994). The clinical inter-
Sheehan, D.V., Lecrubier, Y., Sheehan, K.H.,                    view using DSM-IV: Vol. 2: The difficult patient.
    Amorim, P., Janavs, J., Weiller, E., Hergueta,              Washington, DC: American Psychiatric Press.
    T., Baker, R., & Dunbar, G.C. (1998). The               Shea, S.C. (1998). Psychiatric interviewing: The art of
    Mini-International Neuropsychiatric Inter-                  understanding. A practical guide for psychiatrists,
    view (MINI): The development and valida-                    psychologists, counselors, social workers, nurses,
    tion of a structured diagnostic psychiatric                 and other mental health professionals (2nd ed.).
    interview for DSM-IV and ICD-10. Journal of                 Philadelphia: Saunders.
    Clinical Psychiatry, 59(Suppl. 20), 22–33.


Recommended Readings

Carlat, D. (1999). The psychiatric interview: A practi-
    cal guide. New York: Lippincott, Williams &
    Wilkins.




                    EFFECTIVE
      12            TREATMENT PLANNING


                    Christopher M. Faiver




Effective treatment planning is one of two                  that follows. Moreover, good listening skills
tangible end results of a thorough intake as-               are essential to the derivation of a thorough
sessment of the client. The other result is the             and accurate intake with the consequent
determination of an appropriate diagnosis.                  treatment plan.
Actually, the intake assessment may be                         There are a variety of approaches to effec-
viewed as a process and a vital component of                tive assessment and treatment planning.
counseling and therapy. Often the first con-                These range from the use of psychological
tact clients have with the mental health arena,             tests and inventories (Dougherty & Cham-
assessment sets the tone for the treatment                  blin, 1999; Fisher, Beutler, & Williams,
84     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

1999; Maruish, 1999) to determine the most         Client and Concern Description
efficacious treatment to those that couple di-
                                                   Generally, the formula denoting age, race,
agnosis with corresponding treatment
                                                   gender, and marital status in adults, followed
modalities (DeGood, Crawford, & Jongsma,
                                                   by the words “complaining of . . . ” or “report-
1999; Frances & Ross, 1996; Jensen, 1999;
                                                   ing . . . ” is standard. For example: A 30-year-
Kadden & Skerker, 1999; King & Scahill,
                                                   old Asian female, divorced, complaining of
1999; Klassen, Miller, Raina, Lee, & Olsen,
                                                   anxiety and depression following divorce pro-
1999; Othmer & Othmer, 1994; Paleg &
                                                   ceedings. In the case of children or those
Jongsma, 2000; Seligman, 1990; Spitzer, Gib-
                                                   forced to seek treatment, the formula remains
bon, Skodel, Williams, & First, 1994). The
                                                   the same, with the exception of “whose par-
counselor’s theoretical orientation influ-
                                                   ents report . . . ” or “whom school (or other)
ences choice of treatment and case disposi-
                                                   officials report . . . ” in lieu of the client self-
tion, and the exigencies of third-party
                                                   reporting.
payment and the managed care environment
delimit the need for a precise and measura-
ble treatment plan.                                Psychosocial History
   Intake procedures range from the ex-
tensive and elaborate to the minimal and           Next, one examines the past history of the
concise compilation of data. Nonetheless, a        client by performing a psychosocial history.
basic structure for assessment emerges. This       Relevant historical data are gathered on the
intake assessment process includes several         client, including childhood and adolescence,
components: (1) client description, (2) prob-      current and family of origin history, legal his-
lem description, (3) psychosocial history,         tory, medical history, religious ( belief system)
(4) mental status examination, (5) diag-           history, employment history, educational/vo-
nosis, and (5) treat ment recommendations.         cational history, avocational history, military
First, data are gathered on the client and the     history, history of mental health contacts, and
presenting concern. Next, background infor-        relational/social history.
mation, called the psychosocial history, is
noted, paying special attention to any anom-
                                                   Mental Status
alies—anything out of the ordinary—in the
client ’s past. Finally, the counselor evaluates   Ascertaining of mental status differs from
how the client is functioning presently in         psychosocial history in that the counselor
the consulting room in what is termed the          makes clinical inferences about the client
mental status exam. These data provide the         based on present observations of the client
necessary information from which to draw           rather than on client-reported self-history.
the diagnostic conclusion from the Diagnostic         Another simple formula denotes whether
and Statistical Manual of Mental Disorders,        the client appeared alert and oriented as to
fourth ed. (APA, 1994), as well as to provide      person (who he or she is), place (where he or
suggested       treat ment     recommendations     she is), and time (what the date and time are).
(Faiver, 1988, 1992; Faiver & O’Brien, 1993;       Called “orientation in the three spheres,”
Faiver, Eisengart, & Colonna, 2000; Othmer         some clinicians simply write “Ox3” to note
& Othmer, 1994).                                   that the client appeared alert and oriented. Of
                                                   course, the opposite notation of “disoriented”
                                                   would be recorded for those clients who fit
THE INTAKE PROCESS                                 that description.
                                                      Three other areas of mental status assess-
With the understanding that treatment rec-         ment merit attention:
ommendations emerge from the process of in-
take, it makes sense to describe this process      • Cognitions. Here the counselor explores
in some detail.                                      current functioning in the cognitive arena,
                                                  12 • EFFECTIVE TREATMENT PLANNING                85

  including recent and remote memory, intel-        ing from the process of the interview and,
  lectual level ( below average, average, or        thus, are tentative and subject to modification.
  above average), concrete versus abstract          Possible recommendations include psychologi-
  thinking abilities, judgment, guilt, evidence     cal testing; psychiatric referral; referral to an-
  of hallucinations, delusions.                     other professional; a specific type of therapy,
• Affect. The counselor notes current type,         such as individual, group, family, or marital; a
  appropriateness, level, and intensity of          specific modality, such as stress management,
  emotions, including depression, anxiety,          biofeedback, cognitive-behavioral; hospitaliza-
  and mania.                                        tion; or even no treatment.
• Behaviors. The counselor takes notice of
  any behavioral anomalies, including tics,
  psychomotor agitation or retardation, pres-       THE TREATMENT PLAN
  sured speech, and unusual gestures.
                                                    Formulation of a treatment plan follows in-
   Additionally, the counselor assesses risk of     take. Ideally, the client is as involved in the
harm to self or others to determine level of        process of treatment planning as possible
lethality, ideation, plans, and means. It be-       (Chinman et al., 1999). This involvement helps
hooves the counselor to become familiar with        ensure the investment of the client in his or
agency and ethical policies in this area.           her treatment. By including the client in the
   Finally, the counselor may find it useful to     decision-making process, we teach the client
ask the client the question: “Is there anything     that counseling is a shared process in which
I haven’t asked you that you think I should         clients not only have contributions to make,
know?” Often, other pertinent information           but also have accountability regarding the re-
may result.                                         sults of their therapy (Faiver et al., 2000). Of
                                                    course, the level of client involvement de-
                                                    pends on the severity of diagnosis, level of
Diagnostic Impression (DSM-IV)
                                                    client insight, age, issues of fitness, and the
The counselor draws a diagnostic conclusion         ability, skills, and theoretical orientation of
based on data provided or self-reported by          the counselor. Moreover, conclusions regard-
the client and the clinical inferences observed     ing treatment recommendations are as indi-
by the counselor. Note that the diagnosis is        vidualized as the diagnosis, respecting the
merely an impression and, as such, is subject       uniqueness of the client.
to modification. Data are reported in five             The treatment plan generally follows a
areas, called axes. They include:                   management-by-objective format and, as
                                                    such, is specific, time-limited, and concise.
Axis I     Clinical Syndromes                       Goals are usually the inverse of the problems
           Other Conditions That May Be a           stated and are measurable. For example, a
           Focus of Clinical Attention              client indicating a problem with controlling
Axis II    Personality Disorders                    her anger may have as a goal increased control
           Mental Retardation                       of outbursts, as evidenced by a specific nu-
                                                    merical reduction from five per day to two.
Axis III   General Medical Conditions
                                                    The client signs the treatment plan along with
Axis IV    Psychosocial and Environmental           the counselor, thus providing further invest-
           Problems                                 ment in the treatment process as a social con-
Axis V     Global Assessment of Functioning         tract. We recommend that clients who are
                                                    minors sign along with their parents to en-
                                                    gender their participation. (How often are
Treatment Recommendations
                                                    minors asked to sign anything?)
As with the diagnostic impression, treatment           A simple treatment plan is illustrated in
recommendations are conclusional data result-       Table 12.1.
86         PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

TABLE 12.1       Treat ment Plan Illustration
Problem/              Problem/                                      Treat ment        Expected Date
Concern                 Goal                 Treat ment          of Achievement          Results             Follow-Up

1. Anxiety         Decrease tension       Teach progressive         12/2002        Ct. reports less stress   In 2 months
                                          muscle relaxtion




TABLE 12.2        Intake Form with Treat ment Plan
Client Name                                                 Counselor Name

Date                                                        Length of Interview

     I. Client and problem description:

 II. Psychosocial history:

III. Mental status:
     Cognitions:
     Affect:
     Behaviors:
     Risk of harm to self or others:

IV. Diagnostic impression (DSM-IV)
    Axis I:
    Axis II:
    Axis III:
    Axis IV:
    Axis V:

 V. Treat ment recommendations:

VI. Treat ment plan:


Problem/Concern           Goal         Treat ment Methods       Expected Date of Achievement      Results     Follow-Up

1.



2.



3.



4.



5.

VII. Additional remarks:
                                                    12 • EFFECTIVE TREATMENT PLANNING                      87

   In formulating the treatment plan, coun-           References
selors should pay attention to factors that
                                                      American Psychiatric Association. (1994). Diagnos-
may affect both therapy planning and pro-                  tic and statistical manual of mental disorders (4th
cess. These include whether client problems                ed.). Washington, DC: Author.
are acute or chronic; any socioeconomic limi-         Chinman, M.J., Allende, M., Weingarten, R.,
tations; the amount of structure needed                    Steiner, J., Tworkowski, S., & Davidson, L.
(within the context of least restrictive envi-             (1999). On the road to collaborative treat ment
ronment); legal system considerations; the                 planning: Consumer and provider perspec-
conforming of treatment to a specific diagno-              tives. Journal of Behavioral Health Services and
sis; collaboration with other professionals; the           Research, 26(2), 211–218.
counselor’s time constraints and schedule;            DeGood, D.E., Crawford, A.L., & Jongsma, A.E.
                                                           (1999). The behavioral medicine treatment plan-
the counselor’s competency to deal with spe-
                                                           ner. New York: Wiley.
cific problems; any constraints placed by man-
                                                      Dougherty, L.M., & Chamblin, B. (1999). Assessment
aged care companies; the agency’s capacity                 as and adjunct in psychotherapy. In P.A. Licht-
for dealing with certain problems; the client’s            enberg (Ed.), Handbook of assessment in clinical
ability to deal with his or her problem; and               gerontology (pp. 91–110). New York: Wiley.
any special client needs that must be ad-             Eisengart, S., Eisengart, S., Faiver, C., & Eisengart,
dressed (Faiver et al., 2000).                             J. (1996). Respecting physical and psychoso-
   We encourage counselors to be creative as               cial boundaries of the hospitalized patient:
they work with clients in the design of a                  Some practical tips on patient management.
treatment plan, with the end goal of assist-               Rural Community Mental Health, 23(2), 5 –7.
ing clients in achieving their ideal level of         Faiver, C. (1988). An initial client contact form. In
                                                           P.A. Keller & S.R. Heyman (Eds.), Innovations
functioning. Do your best to meet the
                                                           in clinical practice: A source book (Vol. 7,
client’s needs within the bounds of the code
                                                           pp. 285 –288). Sarasota, FL: Professional Re-
of ethics, of course. Be frank with clients                source Exchange.
about what you and your agency are able to            Faiver, C. (1992). Intake as process. CACD Journal,
do for them, offering referral and assistance              12, 83 –85.
in finding appropriate clinical resources as          Faiver, C., & O’Brien, E. (1993). Assessment of reli-
necessary.                                                 gious beliefs form. Counseling and Values,
   Table 12.2 illustrates a basic process out-             37(3), 176 –178.
line for the clinical intake with focus on            Faiver, C.M., Eisengart, S.P., & Colonna, R. (2000).
treatment recommendations and treatment                    The counselor intern’s handbook (2nd ed.). Pa-
plans.                                                     cific Grove, CA: Brooks/Cole.
                                                      Fisher, D., Beutler, L., & Williams, O. (1999). Mak-
                                                           ing assessment relevant to treat ment plan-
                                                           ning: The STS clinician rating form. Journal of
SUMMARY                                                    Clinical Psychology, 55(7), 825 –842.
                                                      Frances, A., & Ross, R. (1996). DSM-IV case studies:
Effective treatment planning is the culmina-               A clinical guide to differential diagnosis. Wash-
tion of the process of a thorough intake as-               ington, DC: American Psychiatric Press.
sessment on the part of the counselor. The            Jensen, P.S. (1999). Fact versus fancy concerning
basic components of any intake include de-                 the multimodal treat ment study for attention-
scriptions of the client and his or her concern,           deficit /hyperactivity disorder. Canadian Jour-
                                                           nal of Psychiatry, 44(10), 975 –980.
a psychosocial history, and a mental status
                                                      Kadden, R.M., & Skerker, P.M. (1999). Treat ment
examination. These areas of assessment result
                                                           decision making and goal setting. In B.S. Mc-
in the DSM-IV diagnosis and the treatment                  Crady & E.E. Epstein (Eds.), Addictions: A com-
plan itself. This plan, by necessity, is precise,          prehensive guidebook (pp. 216 –231). New York:
to the point, and measurable. Clients should               Oxford University Press.
be as involved as possible in this process of         King, R.A., & Scahill, L. (1999). The assessment
treatment planning.                                        and coordination of treat ment of children and
88      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

    adolescents with OCD. Child and Adolescent            Othmer, E., & Othmer, S.C. (1994). The clinical inter-
    Psychiatric Clinics of North America, 8(3),                view using DSM-IV. Washington, DC: Ameri-
    577–597.                                                   can Psychiatric Press.
Klassen, A., Miller, A., Raina, P., Lee, S.K., & Olsen,   Paleg, K., & Jongsma, A.E., Jr. (2000). The group
    L. (1999). Attention-deficit/hyperactivity dis-            therapy treatment planner. New York: Wiley.
    order in children and youth: A quantitative           Seligman, L. (1990). Selecting effective treatments.
    systematic review of the efficacy of different             Alexandria, VA: American Counseling Asso-
    management strategies. Canadian Journal of                 ciation.
    Psychiatry, 44(10), 1007–1016.
Maruish, M.E. (1999). The use of psychological testing
    for treatment planning and outcomes assessment
    (2nd ed.). Mahwah, NJ: Erlbaum.




                    THE NONMEDICAL THERAPIST’S
      13            ROLE IN PHARMACOLOGICAL
                    INTERVENTIONS WITH ADULTS


                    R. Elliott Ingersoll



In the past 40 years, conceptualizations and              ments available for these disorders than ever
treatments of emotional disorders have                    before (Littrell & Ashford, 1995).
changed drastically. In the recent past, the                  According to the American Psychiatric As-
theoretical base regarding the etiology and               sociation, it is difficult to get an exact count of
treatment of mental and emotional disorders               psychotropic prescriptions written in the
was strongly psychodynamic (Gabbard, 1994).               United States at any given time (T. Tanielian,
Despite trends in brief and cognitive therapies,          Associate Director, Office of Research, per-
this base has become increasingly medical                 sonal communication, February 8, 1999). Psy-
(Cohen, 1993). The medical model emphasizes               chotropic medications accounted for 8.8% of
the biological bases of behavior and pharmaco-            the total prescription drug market in 1994
logical manipulation of these biological bases            and that number is rising (Pincus et al., 1998).
to achieve behavior change (Gabbard, 1994;                The number of visits for psychotropic medica-
Schatzberg, Cole, & DeBattista, 1997). At the             tion to primary care physicians and psychia-
time of this writing, the core treatment for              trists has increased (Pincus et al., 1998), and
many of the mental and emotional disorders                much of the increase is attributable to newer
listed in the Diagnostic and Statistical Manual           antidepressants and the increased use of
(DSM-IV) of the American Psychiatric Associa-             stimulants to treat children and adolescents
tion (1994) is pharmacological (Victor, 1996),            with Attention-Deficit/Hyperactivity Disor-
and there are more pharmacological treat-                 der (ADHD).
  13 • THE NONMEDICAL THERAPIST’S ROLE IN PHARMACOLOGICAL INTERVENTIONS                           89

   The goal of this chapter is to describe the     professional prescribing the client’s medica-
roles of nonmedical mental health profession-      tion is necessary.
als dealing with clients taking psychotropic
medications. The roles discussed include col-
laborator, information broker, and support per-    ETHICAL AND LEGAL CONSIDERATIONS
son. Before discussing the roles, the chapter
begins with a discussion of why it is important    Assuming a mental health professional has at
for nonmedical mental health professionals to      least basic education in psychopharmacology,
acquire knowledge about psychopharmacology         is there a legal or ethical problem with such a
and an overview of the ethical and legal issues.   therapist discussing medications with clients?
   Because this chapter does not provide basic     There are no clear prohibitions against a non-
pharmacological training, it is important to       medical mental health professional talking
emphasize that mental health professionals         with clients about psychotropic medications
should take at least one course in psychophar-     (Patterson, 1996), although this is still a gray
macology and pursue continuing education in        area. Littrell and Ashford (1995) explored the
that area. Courses designed for nonmedical         issue of psychologists discussing psychotropic
mental health professionals should follow the      medications with clients. They noted the his-
level 1 guidelines for psychopharmacology          tory of court decisions on this topic related to
education set forth by the American Psycho-        the nursing and pharmacy professions and
logical Association (APA, 1995). See Ingersoll     concluded, “Given the precedent established in
(in press) for a description of such a course.     other professions, it is unlikely that a psychol-
                                                   ogist’s discussion of medication could be
                                                   construed as practicing medicine without a li-
WHY LEARN ABOUT                                    cense” (p. 241). They concluded that there
PSYCHOTROPIC MEDICATIONS?                          was no basis in case law for assuming that
                                                   psychologists sharing information about psy-
A general, working knowledge of psy-               chotropic medication is illegal. It should be
chopharmacology is important for several           noted that psychologists’ situation might
reasons. First, all mental health professionals    change, as there is a movement to train them
should be able to help their clients under-        to prescribe psychotropic medications. Cur-
stand the treatment options they are likely to     rently, only one U.S. jurisdiction (Guam) has
encounter (Meyer & Dertsch, 1996), and psy-        passed legislation allowing limited prescrip-
chotropic medications are increasingly con-        tion privileges for clinical psychologists (Fox-
sidered treatment options in settings where        hall, 1999; Rabasca, 1999).
counseling and psychotherapy take place                There is no literature exploring related ethi-
(Buelow, Herbert, & Buelow, 2000; Faiver,          cal issues for counselors, social workers, and
Eisengart, & Colonna, 2000). Many clients of       other mental health professionals, and research
master’s-level counselors, social workers,         in this area is needed. It is important to note
and school psychologists are taking some           that in the American Counseling Association
form of psychotropic medication, but re-           (ACA) Code of Ethics and Standards of Prac-
search studies have noted that these profes-       tice, section A.1 states that a primary responsi-
sionals lack training in psychopharmacology        bility of counselors is to promote clients’
(Bentley, Farmer, & Phillips, 1991; Kra-           welfare. This includes being knowledgeable
tochwill, 1994; West, Hosie, & Mackey, 1988).      about treatment options, which can include
Second, mental health professionals need an        supplementing counseling with psychotropic
understanding of how taking medications or         medication prescribed by a physician. Coun-
noncompliance with medication prescrip-            selors who may discuss psychotropic medica-
tions can affect a client’s progress in coun-      tions with clients need to closely observe
seling. Understanding these issues can help        the ethical principles for collaborating with co-
therapists decide when referral back to the        operating agencies and professionals (see
90     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

Glosoff, this volume; Patterson, 1996). More       doctor’s attitude toward counseling and psy-
and more, it seems that the increasing use of      chotherapy.
psychotropic medications to treat mental and          Doctors who view psychotropic medica-
emotional disorder leads scholars to conclude      tions and therapy as complementary (and
that legal problems may result from a thera-       trust the credentials of the therapist) typi-
pist’s not pursuing basic knowledge in psy-        cally appreciate the informed colleague strat-
chopharmacology (Buelow, Herbert, & Buelow,        egy. In this type of relationship, the doctor is
2000; Patterson, 1996).                            as interested in what the therapist knows
                                                   about the client’s progress as the therapist is
                                                   in what the doctor knows about the client’s
                                                   medication regimen. Doctors who are skepti-
IMPORTANT ROLES FOR THE
                                                   cal about the benefits of complementing psy-
NONMEDICAL THERAPIST
                                                   chotropic medication with therapy (or who
                                                   mistrust the credentials of a particular thera-
Mental Health Professional as Collaborator
                                                   pist) are best approached through the “one-
Seeing a client who may be taking a psy-           down” strategy. In this strategy, the therapist
chotropic medication raises several possible       presents as one who needs to learn from the
collaboration situations. Assuming the client      doctor and graciously (if not genuflectively)
has signed the appropriate release of informa-     absorbs whatever expertise the doctor can
tion form, therapists may find themselves col-     share in the collaboration.
laborating with physicians, psychiatrists,            In the collaborative relationship with
significant others, or members of extended         physicians, therapists have the opportunity to
family.                                            check their understanding of the prescribed
Collaborating with Prescribing Professionals.      medication, ask informed questions, and pro-
When considering prescribing professionals in      vide feedback about the client’s progress in
mental health, psychiatrists are usually the       therapy. The collaborative relationship with
first professionals to come to mind. Some ther-    medical personnel is an excellent opportunity
apists may have the luxury of choosing a partic-   to gain a greater understanding of clients’ re-
ular psychiatrist to collaborate with, but the     sponses to medication. This is particularly
majority of mental health professionals do not.    important if the client is on multiple medica-
These professionals are often working with a       tions. Although informed questions are ap-
psychiatrist who has a heavy caseload and may      propriate regarding whether a certain client
get to spend only 10 minutes with the client. In   would benefit from a particular medication, it
those instances, psychiatrists may rely more on    is not appropriate to lobby doctors to pre-
the nonmedical therapist for updates regarding     scribe clients certain medications. Such lob-
the client’s progress. Although psychiatrists      bying presumes a medical knowledge that is
specialize in the prescription of medications      usually outside the expertise of a nonmedical
for mental and emotional disorders, general        therapist. As Patterson (1996) noted, the ther-
practitioners write a significant number of        apist’s role is to “support, not supplant” the
prescriptions for psychotropic medications.        medical professional’s role.
Whatever the specialty of the prescribing pro-     Collaborating with Family Members and Signifi-
fessional, a thoughtful, well-planned collabora-   cant Others. Mental health therapists whose
tive relationship can facilitate the client’s      clients are taking medications often will be
treatment (Imhorf, Altman, & Katz, 1998).          approached by significant others and family
   Collaboration strategies may be said to fall    members who may hold a variety of attitudes
on a general continuum between taking a            toward medication, ranging from polite cu-
“one-down” position to being perceived and         riosity to unbounded hostility. In many cases,
treated as an informed colleague. The strat-       loved ones do not have access to as much time
egy one chooses depends on the disposition         with the prescribing professional as with the
of the medical doctor in question and the          mental health therapist. Again, assuming the
  13 • THE NONMEDICAL THERAPIST’S ROLE IN PHARMACOLOGICAL INTERVENTIONS                            91

appropriate releases of information have been      and interpreting research studies. For quick
signed by the client, therapists can provide an    updates and summaries of research, mental
important service by helping loved ones un-        health professionals can turn to newsletters
derstand why a client is on a medication and       such as Psychopharmacology Update published
what it is hoped that the medication will do       by Manisses Corporation or the electronic
for the client. It is important to be alert to     newsletter Medscape (pharmacotherapy.med-
misinformation that client’s loved ones may        scape.com). As with any information, though,
have regarding what a medication can and           it is preferable to get as close to the source as
cannot do. One woman whose father was suf-         possible.
fering from the early stages of Alzheimer’s            Taking the role of information broker does
type dementia believed that a medication           not translate into blind support and endorse-
prescribed (in this case, donepezil) could         ment of the medical model. Rather, this role
cure the condition. Although the prescribing       helps clients understand what the science of
physician had already explained that the           the medical model can and cannot offer them.
medication could only slow the progress of         Regarding the client above who wants to try St.
the disease, the woman still held firm to the      John’s Wort, there may be no harm in his try-
belief that it would cure her father. In this      ing it if postponing medication does not put
case, the therapist (a clinical counselor)         him at risk. A good information broker would
worked several sessions helping the woman          want to know that herbal compounds are noto-
through the emotional pain that came with          riously variable regarding their potency and
conscious awareness of her father’s condition      ingredients (Gutherie, 1999), that the results of
and helped her make the most of the extra          studies of St. John’s Wort are currently mixed
time she got with her father because of the        (Health, 2000; Volz, 1997), and that St. John’s
benefits of the medication.                        Wort may have harmful interactions with
                                                   other drugs. Clearly, the safest course of action
                                                   for the client in question is to talk to his physi-
Mental Health Professional as                      cian to be certain that St. John’s Wort is not
Information Broker                                 contraindicated. Certainly, the herb may have
Suppose you have a client who comes in and         beneficial effects or may act as a placebo for
says, “I decided not to talk to my doctor about    the client in question. Clients will make their
an antidepressant. I am going to drink tea         own choices on these matters and many never
made from St. John’s Wort instead. I saw a         share their use of herbaceuticals with their
great article on it on the Internet.” One thing    physicians (Gutherie, 1999). The nonmedical
there is no shortage of in our society is infor-   therapist as information broker is in a good po-
mation, and that includes information on psy-      sition to steer the client toward quality infor-
chotropic medications. What is important is        mation as well as explore the possibility of a
knowing where to go for good information and       medical consultation before trying the herbal
how to evaluate that information.                  preparation.
   Advances in the number and understanding
of psychotropic medications are increasing at a
                                                   Mental Health Professional as Support Person
dizzying pace. Most clients taking psy-
chotropic medications could use an informa-        Clients taking medication often need support
tion broker to assist them in understanding        for a variety of issues. Consider the case of a
those medications. I use the term “broker”         woman who was suffering antidepressant-
here in the sense of one who acts as an inter-     induced sexual dysfunction and waited six
mediary to arrange information about psy-          months before mentioning it because she was
chotropic medications. Obviously, to be a good     embarrassed to talk about sexuality. Although
information broker with clients, nonmedical        the client was seeing the therapist (a clinical
mental health professionals need basic training    social worker) to change life situations corre-
in understanding psychotropic medications          lated with her depressive episodes, dealing
92     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

with the side effect became a therapeutic con-       such topics as how medications may work dif-
cern. The client’s difficulty talking about sexu-    ferently in women (Yaeger & Hendrick, 1998)
ality was similar to many other areas of her life    and the effects of medications on breast-
where she had difficulty “finding her voice”         feeding women (Stowe et al., 1997). The re-
and stating what she wanted. Her case had a          search on racial differences that does exist is
positive outcome and she was able to speak to        in its infancy and typically looks at effects be-
her physician about the problem and have her         tween Caucasians and African Americans or
medication adjusted to alleviate it.                 Asians and Asian Americans. There are many
Supporting Compliance with Medication Regimens.      issues to be dealt with, including the inaccu-
Noncompliance with medication regimens               rate classifying of different groups under the
varies greatly across populations, but it is esti-   same label (such as “Hispanic”) ( Jacobsen &
mated that between 25% and 80% of patients           Comas-Diaz, 1999).
with various disorders are noncompliant with             Differences in physiology are important to
their medications (Sackett, 1980). Patterson         such research, and cultural attitudes toward
(1996) has noted that noncompliance may be           taking medication or herbaceuticals and
defined as “any departure from the instruc-          lifestyle issues from culture to culture are
tions for proper use of the medication” (p. 70).     equally important. One example cited by Jacob-
Patterson wrote that the role of nonmedical          sen and Comas-Diaz (1999) is the rate of coffee
professionals in supporting compliance in-           consumption among Latinas and how caf-
cludes talking regularly with clients about          feine’s sympathomimetic effects can worsen
whether they are in fact taking the medication       many symptoms of mental illness as well as af-
as prescribed, whether the medication seems          fect the hepatic enzymes responsible for drug
to be relieving symptoms, and whether the            metabolism.
client is suffering from any side effects.
Supporting Culturally Diverse Clients. The field
of psychopharmacology is just beginning to in-       SUMMARY
vestigate the relevance of cultural variables as
they may relate to differential attitudes to-        In this era of biological psychiatry, the non-
ward and responses to medication. This has           medical mental health professional has impor-
been described as ethnopharmacotherapy               tant roles to play when clients’ therapy is
(Lawson, 1999) and includes looking at vari-         complemented with psychotropic medication.
ables of diversity and their relationship to         As collaborator, information broker, and sup-
medication. Variables of diversity include race,     port person, the nonmedical mental health
ethnicity, gender, age, ability/disability, and      professional provides services necessary for
sexual orientation. Lawson noted that most           quality mental health care. With proper train-
psychiatric journals publishing biological re-       ing, continuing education, and ethical practice,
search do not include data regarding the race        the nonmedical mental health professional
of the subjects. This despite the fact that dif-     will continue to be an indispensable part of the
ferent ethnic groups may require different           total treatment team.
doses, may have different risks for certain side
effects, and may receive misdiagnoses due to
                                                     References
symptom expression that deviates from the
dominant cultural expression.                        American Psychiatric Association. (1994). Diagnos-
                                                         tic and statistical manual of mental disorders (4th
   Probably the most developed body of re-
                                                         ed.) Washington, DC: Author.
search on differential effects of medication ex-     American Psychological Association. (1995). Cur-
amines gender. It is estimated that 70% of the           riculum for level one training in psychopharmacol-
psychotropic medications prescribed in the               ogy. Washington, DC: Author.
United States are prescribed to women (Ogur,         Bentley, K.J., Farmer, R., & Phillips, M.E. (1991).
1986). Newer research is shedding light on               Student knowledge of and attitudes toward
  13 • THE NONMEDICAL THERAPIST’S ROLE IN PHARMACOLOGICAL INTERVENTIONS                                         93

     psychotropic drugs. Journal of Social Work Edu-             intervention in adult and adolescent psychopathol-
     cation, 27, 279–289.                                        ogy. Boston: Allyn & Bacon.
Buelow, G., Herbert, S., & Buelow, S. (2000). Psy-          Ogur, B. (1986). Long day’s journey into night:
     chotherapist ’s resource on psychiatric medica-             Women and prescription drug abuse. Women
     tions: Issues of treatment and referral. Pacific            and Health, 11, 99–115.
     Grove, CA: Brooks/Cole.                                Patterson, L.E. (1996). Strategies for improving
Cohen, C.I. (1993). The biomedicalization of psy-                medication compliance. Essential Psychophar-
     chiatry: A critical overview. Community Men-                macology, 1, 70–79.
     tal Health Journal, 29, 509–521.                       Pincus, H.A., Tanielian, T.L., Marcus, S.C., Olfson,
Faiver, C.M., Eisengart, S., & Colonna, R. (2000).               M., Zarin, D.A., Thompson, J., & Zito, J.M.
     The counselor intern’s handbook (2nd ed.). Pa-              (1998). Prescribing trends in psychotropic
     cific Grove, CA: Brooks/Cole.                               medications. Journal of the American Medical
Foxhall, K. (1999). Town hall meeting focuses on                 Association, 279, 526 –531.
     gaining prescription privileges. APA Monitor,          Rabasca, L. (1999). Guam psychologists gain right
     30, 30.                                                     to prescribe. APA Monitor, 30, 6.
Gabbard, G.O. (Ed.). (1994). Treatment of the DSM-          Sackett, D. (1980). Is there a compliance problem? If
     IV psychiatric disorders. Washington, DC:                   so, what do we do about it? In L. Lasagna (Ed.),
     American Psychiatric Press.                                 Controversies in therapeutics. Philadelphia:
Gutherie, S.K. (1999, September 24). Herbaceuticals              Saunders.
     in psychiatry. Unpublished lecture given at the        Schatzberg, A.F., Cole, J.O., & DeBattista, C.
     Medical College of Ohio, Toledo.                            (1997). Manual of clinical psychopharmacology
Imhof, J.E., Alt man, R., & Katz, J.L. (1998). The re-           (3rd ed.). Washington, DC: American Psychi-
     lationship between psychotherapist and pre-                 atric Press.
     scribing psychiatrist. American Journal of             Stowe, Z.N., Owens, M.J., Landry, J.C., Kilts, C.D.,
     Psychotherapy, 52, 261–272.                                 Ely, T., Llewellyn, A., & Nemeroff, C.B. (1997).
Ingersoll, R.E. (in press). Teaching a course in psy-            Sertraline and desmethylsertraline in human
     chopharmacology to counselors: Justification,               breast milk and nursing infants. American
     structure, and methods. Counselor Education                 Journal of Psychiatry, 154, 1255 –1260.
     and Supervision.                                       Victor, B.S. (1996). Transpersonal psychopharmacol-
Jacobsen, F.M., & Comas-Diaz, L. (1999). Psy-                    ogy and psychiatry. In B.W. Scotton, A.B. Chi-
     chopharmacologic treat ment of Latinas. Essen-              nen, & J.R. Battista (Eds.), Textbook of
     tial Psychopharmacology, 3, 29– 42.                         transpersonal psychiatry and psychology. New
Kratochwill, T.R. (1994). Psychopharmacology for                 York: Basic Books.
     children and adolescents: Commentary on                Volz, H.P. (1997). Controlled clinical trials of hy-
     current issues and future challenges. School                pericum extracts in depressed patients: An
     Psychology Quarterly, 9, 53 –59.                            overview. Pharmacopsychiatry, 30(Suppl. 2),
Lawson, W.B. (1999). The art and science of                      72–76.
     ethnopharmacotherapy. In J.M. Herrera, W.B.            West, J.D., Hosie, T.W., & Mackey, J.A. (1988,
     Lawson, & J.J. Sramek (Eds.), Cross-cultural                March). The counselor’s role in mental health:
     psychiatry. New York: Wiley.                                An evaluation. Counselor Education and Super-
Littrell, J., & Ashford, J. (1995). Is it proper for psy-        vision, 233 –239.
     chologists to discuss medications with clients?        Yeager, D., & Hendrick, V. (1998). The faces of depres-
     Professional Psychology: Research and Practice,             sion throughout the female life cycle [video].
     238, 238–244.                                               (Available from Interactive Medical Networks,
Meyer, R.G., & Deitsch, S.E. (1996). The clinician’s             1375 Piccard Drive, Suite 325, Rockville, MD
     handbook: Integrated diagnostics, assessment, and           20850)
                  GUIDELINES FOR COUNSELING
     14           MANDATED AND
                  NONVOLUNTARY CLIENTS


                  Ronald H. Rooney




Mental health counselors frequently assess or            ited options covered under their plan (Strom-
treat clients who did not choose to work with            Gottfried, 1998).
the counselor. Such clients have often been
considered resistant, as if their reluctance were
                                                         Constructs Related to Process and Outcome
part of their pathology rather than a reflection
of their coerced circumstances. There is reason          Outcomes can be improved to the extent that
to believe that coerced or pressured contact             there is motivational congruence or a fit between
will increase, as the number of clients legally          the involuntary client’s own concerns and
mandated to receive treatment is increasing.             those of external sources of pressure. Failing
This chapter outlines constructs and skills de-          agreement, the oppositional behavior exhib-
signed to assist you in increasing voluntarism           ited by court-ordered and nonvoluntary clients
with mandated and nonvoluntary clients.                  is often labeled resistance. That oppositional
                                                         behavior might better be reframed as disagree-
                                                         ment with the views of their problems held by
MAJOR CONSTRUCTS                                         others. Fruitful sources of intervention come
                                                         from reframing expectable opposition from pe-
Constructs Related to Clients                            jorative labels such as resistance to reactance, or
                                                         the normal response that occurs when a per-
Mental health counselors provide assessments
                                                         son experiences a threat to valued beliefs and
or treatments for legally mandated or court-
                                                         behaviors (Brehm, 1976). In addition, involun-
ordered clients who seek assistance under the
                                                         tary clients often manifest self-presentation
pressure of a court order. They also provide
                                                         strategies designed to put themselves in the
services for nonvoluntary clients who seek as-
                                                         best light to influence the counselor’s recom-
sistance under formal pressures from agencies,
                                                         mendation. For example, it is common for a
officials, and employers and informal pres-
                                                         person to ingratiate, supplicate, or attempt to
sures from parents, spouse, partner, and chil-
                                                         intimidate a counselor considered to have
dren (as in the case of the elderly) (Rooney,
                                                         power over important decisions such as child
1992). For example, it has been noted that
                                                         custody ( Jones & Pittman, 1982).
clients receiving services under managed care,
                                                            Efforts to influence involuntary client
though not legally mandated, often find lim-
                                                         beliefs and behaviors often include forms of
                                                         confrontation designed to show clients inconsis-
                                                         tencies between their own values and behav-
The author wishes to thank Michael Chovanec and
                                                         iors. Efforts to achieve long-lasting changes
Carol Kuechler for their useful comments on ear-         often require persuasion methods designed to
lier drafts of this chapter.                             influence those values and behaviors and

                                                    94
       14 • GUIDELINES FOR COUNSELING MANDATED AND NONVOLUNTARY CLIENTS                           95

aimed at achieving self-attribution, in which        with penalties for failure to participate, have
clients come to acknowledge changes as being         participated at a high rate without significant
in their own best interest rather than simply        alienation from counselors utilizing the
ways to avoid punishment or attain rewards           penalties (Riccio & Hasenfeld, 1996).
(Rooney, 1992).                                         Similarly, nonvoluntary clients mandated to
                                                     receive counseling services from an employee
                                                     assistance program under a “last-chance con-
Constructs Related to Ethics
                                                     tract” have fared better at 13- to 25-month
The helping professions are often committed to       follow-up in terms of fewer absences and sick
the empowerment of vulnerable clients, assist-       days than other voluntary participants in the
ing them in reaching greater capacity to influ-      program (Keaton & Yamatani, 1993). On the
ence decisions important to them. Ethical            other hand, clients believed to be mentally ill
conflicts arise when intervention with involun-      and imminently violent who have been invol-
tary clients involves paternalism or actions con-    untarily hospitalized have been likely to com-
sidered to be in a client’s best interest, whether   mit assault and battery one day after release
or not the client chooses it. Similarly, benefi-     (Catalano & McConnell, 1996). Hence, coer-
cence refers to interventions designed to en-        cion sometimes results in decreases in nega-
hance a vulnerable client’s quality of life          tive behavior, but concerns are raised about
whether or not the client chooses it (Murdach,       effectiveness when impairment is high. The
1996). Limited beneficence applies to selected       following three sections summarize research
abrogation of wishes, such as when a psychi-         findings on nonvoluntary clients related to
atric nurse temporarily limits visits for the wel-   client characteristics, program characteristics,
fare of a hospitalized patient. When there is        and treatment outcome.
more severe impairment and the effects are
longer lasting, selective beneficence applies; for
                                                     Findings Related to Client Characteristics
example, physically ill patients might not have
the right to refuse treatment. Extensive benefi-     Persons of color are overrepresented in more
cence occurs when the limitation to function-        restrictive forms of treatment, such as juve-
ing is substantial, as when the person has a         nile treatment and out-of-home care. Hence,
psychotic condition. In these instances, inter-      involuntary clients are more likely to be cul-
ference with wishes for best interest may occur      turally different from counselors than in
relating to many behaviors while suffering           most voluntary circumstances (Rooney, 1992).
with a condition uncontrolled by medication.            Involuntary clients coerced into program
The challenge for mental health counselors is        participation have, in some cases, approved of
hence to respect self-determination to the ex-       the mandate and not experienced the kind of
tent possible while also acting with appropriate     alienation from helpers that might be expected
paternalism and beneficence.                         (Kramer & Washo, 1993; Riccio & Hasenfeld,
                                                     1996).
                                                        Clients of all levels of voluntarism vary on
FINDINGS FROM THEORY, RESEARCH,                      a range of readiness for change (Prochaska,
AND PRACTICE                                         DiClemente, & Norcross, 1992). Precontempla-
                                                     tors have not considered the problem serious
Court-ordered clients have been shown to ex-         and have not attempted to change. Contem-
perience gains from required participation in        plators, on the other hand, are aware that oth-
helping programs. For example, court-ordered         ers consider the problem serious and have
recipients of drug treatment have had signifi-       considered making changes. One study at in-
cantly fewer arrests at 30-month follow-up           take indicated that involuntary clients were
than matched probationers not receiving the          overrepresented, as would be expected, in the
drug treatment (Peters & Murrin, 2000). Par-         precontemplation and contemplation phases
ticipants in welfare-to-work programs, faced         (O’Hare, 1996). However, equally significant
96     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

is the fact that as many as 25% of initially in-    domestic violence perpetrators, it has been sug-
voluntary clients had already moved at first        gested that those confrontation methods that
contact to considering decisions or taking ac-      assist involuntary clients in examining their
tion to change. Hence, the counselor should         own behavior and values for inconsistencies
not assume that legally mandated clients nec-       in a nonjudgmental, caring manner are more
essarily lack motivation for change.                likely to stimulate dissonance (Kear-Colwell &
    Concerns are raised about whether in-           Pollock, 1997; Murphy & Baxter, 1997).
formed consent is actually possible with in-           Involuntary clients are more likely to be ef-
voluntary clients when available choices            fected by a confrontive message if the value
contain significant rewards and punishments.        confronted is strong, their current behavior is
Informed consent with involuntary clients           inconsistent with what they consider to be
should include honest information that the re-      ideal behavior, and they are dissatisfied with
sults of an assessment may not result in the        their current behavior (Sawa & Sawa, 1988).
outcome desired by the client and should in-        For example, conflicting parents who are en-
clude disclosure of responsibilities to other       gaged in child custody concerns might be in-
parties besides the client. For example, a          fluenced about talking negatively about their
counselor who does a custody assessment             former spouse to the children if the effects
must ethically inform parents that a primary        can be seen as inconsistent with their value of
responsibility is to the court in assisting the     loving and protecting their children.
judge to make a decision in the best interest of       Involuntary clients can be expected to expe-
the child (Regehr & Angle, 1997).                   rience a less negative reaction to contact if they
                                                    can choose among alternatives, even when
                                                    those choices are constrained (Rooney, 1992).
Findings Related to Program Characteristics
                                                    That is, the choice among alternative forms or
Interviewing that resembles interrogation, in-      locations for receiving chemical dependency
cluding asking an involuntary client to explain     evaluations or domestic violence treatment is
his or her behavior, may be less useful than        more of a choice than deciding between treat-
stating the information available to the coun-      ment and prosecution.
selor about the reason for contact (Brodsky &
Lichtenstein, 1999). For example, the counselor
                                                    Findings Related to Treatment Outcome
might say: “You were referred to me for an
evaluation by your employer. I would like to        Outcomes are improved when involuntary
hear how you feel about this referral.”             clients are socialized to roles such that they
   Programs that are primarily based on the         are clear about what to expect from coun-
threat of coercion face the problem of needing      selors and the helping process and what will
extensive surveillance of client acts and the       be expected from themselves as clients
ability to respond rapidly and decisively to        (Rooney, 1992).
violations to be effective (Riccio & Hasenfeld,        Clients are also more likely to be invested in
1996).                                              treatment alternatives when they have partici-
   Programs that emphasize personal motiva-         pated in the construction of the treatment plan
tion for success through persuasion methods         (Rooney, 1992). If the treatment plan is con-
have also been successful in generating strong      structed by the counselor or developed by rote
participation (Riccio & Hasenfeld, 1996). Such      in a program, the risk is that the involuntary
methods may produce longer-lasting changes          client will feel powerless, experience reac-
through self-attribution than those based pri-      tance, and oppose those plans in part because
marily on compliance.                               he or she did not have a significant part in de-
   Confrontation methods that demean and            veloping them.
disrespect the involuntary client run the risk of      The long-lasting effects of treatment con-
reinforcing abusive beliefs that “might makes       tacts based on coercion and the appropriate use
right.” In working with sexual offenders and        of persuasive methods designed to facilitate
       14 • GUIDELINES FOR COUNSELING MANDATED AND NONVOLUNTARY CLIENTS                             97

self-attribution with lower-functioning persons      information pertinent to client concerns is
remain unanswered questions.                         shared (Saunders & Hanusa, 1986; Thomas &
                                                     Caplan, 1999).


SPECIFIC RECOMMENDATIONS                             Recommendations for Dealing with
FOR THERAPISTS                                       Difficult Behaviors

                                                     Client opposition in the form of hostility, pas-
Assessment and Initial Contact
                                                     sivity, or passive-aggressive behavior is to be
Mental health counselors should consider in          expected when a client feels faced with unde-
their assessment of all clients that their moti-     sirable alternatives. Labeling this behavior
vation to seek help may emerge at least ini-         negatively is less useful than empathizing
tially from pressure—formal, informal, or            with the feeling of pressure in affirming the
legally mandated—from outside themselves.            involuntary client’s sense of reality as a per-
For example, children and adolescents are            son in a difficult situation. For example, a
rarely voluntary in the sense of seeking assis-      statement such as “I know this situation is
tance for concerns of their own (Berman-Rossi        difficult for you. I don’t like it when I am pres-
& Rossi, 1990).                                      sured to do things either” may help the client
   Initially, try hearing out involuntary clients’   feel more understood and diminish urges to
view of the situation, their story, and convey-      act aggressively.
ing empathically that this view is understood.           Behavior often labeled as resistance can
This should help the counselor achieve motiva-       also be reframed as ambivalent, in the sense
tional congruence (De Jong & Berg, 1999).            that the involuntary client has not made a de-
Once a relationship is established, therapists       cision to act. The counselor can support
can explore the involuntary client’s view of         statements that draw on the involuntary
how the situation would look if the problem, as      client’s own motivation (Rollnick & Morgan,
if by a miracle, were no longer present. This        1995). For example, a counselor might say
variation of the Adlerian “magic questions” is       “Part of you is drawn to wait and see
useful in helping the client reach motivational      whether you can handle this problem on
congruence and self-attribution (De Jong &           your own. Another part of you wants to
Berg, 1999).                                         make a decision to seek help that might be
   With many nonvoluntary clients, there will        difficult for you but that you also think could
be legally mandated and nonnegotiable op-            be best for your family.”
tions. These should be presented in a matter-            Of course, there will be situations where
of-fact, nonjudgmental fashion. For example,         the counselor feels a need to use confrontation.
stating “These are the legal requirements for        Confrontation should be carried out sparingly,
what you and I have to do” at least acknowl-         in the context of a respectful, trusting relation-
edges the legal parameters of the situation.         ship. Confrontations often occur when the in-
Given the legal parameters, therapists can           voluntary client has severely harmed another,
then explore all options available to the client     broken the law, or plans to do either of these.
to pursue informed consent and reduce reac-          Confrontations will be more effective if there
tance. For example, stating “Within those re-        is a conflict between the behavior and the per-
quirements, we have some choices about how           son’s own goals. Rather than confronting in
we proceed” may facilitate more exploration          the form of a statement, asking a question
within clients regarding their situation.            about conflict among attitudes, values, and be-
   It should be remembered that involuntary          havior may be more likely to stimulate disso-
clients can be assisted in group settings as         nance (Rooney, 1992). For example, a counselor
well as in individual work. Dropout rates            meeting with a parent who has left a small
appear to decrease when involuntary                  child without supervision might say “You say
clients feel understood by group leaders and         that you would never do anything to harm or
98     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

endanger your child. If a fire had broken out,         SUMMARY
what would the child do?”
                                                       Many clients have been mislabeled as resist-
                                                       ant, reluctant, unmotivated, and hostile when
Recommendations for Contracting with Clients
                                                       in fact they never chose to become clients. By
A contracting process that includes both               being sensitive to legal and nonvoluntary
nonnegotiable requirements and negotiable              pressures, the counselor can take concrete
alternatives is recommended for seeking moti-          steps to enhance voluntarism and empower
vational congruence and enhancing self-                involuntary clients to improve their situation.
attribution. As a first priority in exploring
contracting, it is recommended that the coun-
selor explore agreements that are agreeable            References
mandates or reframed options that permit in-           Berman-Rossi, T., & Rossi, P. (1990, April). Confi-
voluntary clients to reach both their own goals             dentiality and informed consent in school so-
and those of the referral source (Rooney, 1992).            cial work. Social Work in Education, 195 –207.
For example, “You want to raise your children          Brehm, S.S. (1976). The application of social psychol-
as you see fit without agency interference. By              ogy to clinical practice. New York: Wiley.
collaborating with the agency in carrying out a        Brodsky, S.L., & Lichtenstein, B. (1999). Don’t ask
parenting assessment, you can reach your goal               questions: A psychotherapeutic strategy for
of being left alone.”                                       treat ment of involuntary clients. American Jour-
                                                            nal of Psychotherapy, 53(2), 215 –220.
    A second priority in contracting is to ex-
                                                       Catalano, R., & McConnell, W. (1996). A time-se-
plore a let ’s make a deal or quid pro quo con-
                                                            ries test of the quarantine theory of involun-
tract, in which the involuntary client can
                                                            tary commit ment. Journal of Health and Social
receive an incentive in exchange for working                Behavior, 37, 381–387.
on the problem of concern to the referral              De Jong, P., & Berg, I.K. (1999, March 10–13).
source. For example, a nonvoluntary client can              Co-constructing cooperation with mandated
work on an additional voluntary problem of                  clients. Presentation at annual program meet-
his or her own choosing; a court-ordered                    ing of Council on Social Work Education, San
client can be offered an incentive to make                  Francisco.
compliance more attractive (Rooney, 1992).             Jones, E.E., & Pitt man, T.S. (1982). Toward a gen-
    A third priority in contracting is to explore           eral theory of strategic self-presentation. In
a get rid of the pressure contract, in which the in-        J. Sals (Ed.), Psychological perspectives on the
                                                            self. Hillsdale, NJ: Erlbaum.
voluntary client contracts to get rid of the un-
                                                       Kear-Colwell, J., & Pollock, P. (1997). Motivation or
wanted pressure from others. For example, “It
                                                            confrontation: Which approach to the child
sounds as if you would like to get the county               sex offender? Criminal Justice and Behavior, 24,
off your back, is that right? What do you have              20–33.
to do to get the county off your back?”                Keaton, B., & Yamatani, H. (1993). Benefits of
    When involuntary clients agree to work on               mandatory EAP participation: A study of em-
a contract, sometimes that work entails agree-              ployees with last chance contracts. Employee
ing to carry out one or more disagreeable tasks or          Assistance Quarterly, 9(1), 67–77.
actions that may be experienced as inherently          Kramer, L., & Washo, C.A. (1993). Evaluation of a
punishing. Involuntary clients can be assisted              court-mandated prevention program for di-
to enhance their willingness to comply by par-              vorcing parents: The Children First Program.
                                                            Family Relations, 42, 179–186.
ticipating in the selection of the order in which
                                                       Murdach, A.D. (1996). Beneficence re-examined:
the tasks are completed. For example, they can
                                                            Protective intervention in mental health. So-
suggest which task they would like to begin                 cial Work, 41(1), 26 –32.
with. They can also plan to reward themselves          Murphy, C.M., & Baxter, V.A. (1997). Motivating
for completing the task, and they can consider              batterers to change in the treat ment context.
the consequences of failure to complete the                 Journal of Interpersonal Violence, 12(4),
disagreeable task (Rooney, 1992).                           607–619.
                         15 • USING TEST DATA IN COUNSELING AND CLINICAL PRACTICE                             99

O’Hare, T. (1996). Court-ordered versus voluntary        Sawa, S.L., & Sawa, G.H. (1988, April). The value
     clients: Problem differences and readiness for          confrontation approach to enduring behavior
     change. Social Work, 41(4), 417– 422.                   modification. Journal of Social Psychology, 128
Peters, R.H., & Murrin, M.R. (2000). Effectiveness           207–215.
     of treat ment-based drug courts in reducing         Strom-Gottfried, K. (1998). Informed consent
     criminal recidivism. Criminal Justice and Be-           meets managed care. Health and Social Work,
     havior, 27(1), 72–96.                                   23(1), 25 –33.
Prochaska, J., DiClemente, C.C., & Norcross, J.C.        Thomas, H., & Caplan, T. (1999). Spinning the
     (1992). Transtheoretical therapy: Toward a              group process wheel: Effective facilitation
     more integrative model of change. Psy-                  techniques for motivating involuntary client
     chotherapy: Theory, Research and Practice, 19,          groups. Social Work with Groups, 21(4), 3 –21.
     276 –288.
Regehr, C., & Angle, B. (1997). Coercive inf luences:
                                                         Resources for Further Study
     Informed consent in court-mandated social
     work practice. Social Work, 42(3), 300–306.         Ivanoff, A., Blythe, B.J., & Tripodi, T. (1994). Invol-
Riccio, J., & Hasenfeld, Y. (1996). Enforcing a par-          untary clients in social work practice: A research-
     ticipation mandate in a welfare-to-work pro-             based approach. New York: Aldine De Gruyter.
     gram. Social Service Review, 70, 516 –542.          Rooney, R.H. (1992). Strategies for work with involun-
Rollnick, S., & Morgan, M. (1995). Motivational in-           tary clients. New York: Columbia University
     terviewing: Increasing readiness for change. In          Press.
     A. Washton (Ed.), Psychotherapy and substance       Training and consultation for work with involun-
     abuse: A practitioner’s handbook (pp. 179–191).          tary clients and videotapes on practice with
     New York: Guilford Press.                                involuntary clients are available from Ronald
Rooney, R.H. (1992). Strategies for work with involun-        Rooney, School of Social Work, 1404 Gortner
     tary clients. New York: Columbia University              Avenue, University of Minnesota, St. Paul,
     Press.                                                   MN. 55108, rrooney@che.umn.edu.
Saunders, D., & Hanusa, D. (1986). Cognitive-be-         Videotape entitled Talking Solutions with Mandated
     havioral treat ment of men who batter: The               Clients is available from the Brief Family
     short-term effects of group therapy. Journal of          Treat ment Center, P.O. Box 13736 Milwaukee,
     Family Violence, 1, 357–372.                             WI 53213.




                    USING TEST DATA IN
      15            COUNSELING AND
                    CLINICAL PRACTICE


                    Kathryn C. MacCluskie



Assessing client problems, strengths, and in-            term assessment refers to procedures as un-
terpersonal functioning is an inherent compo-            structured as intake or mental status inter-
nent of counseling and clinical activity. The            views, and as highly structured as standardized
100     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

intelligence instruments. There are myriad oc-      MAJOR CONSTRUCTS AND TERMINOLOGY
casions when it may be beneficial for a client to
participate in structured clinical assessments      In the medical fields, measurements are often
using standardized tests. This chapter describes    made on specific, identifiable physical entities,
these occasions and how the data generated          such as a red blood cell count or blood pressure.
from standardized instruments can be applied        In mental health, in contrast, measurements are
to ongoing work with clients. A counselor may       based largely on hypothetical constructs. A hypo-
choose to use test data to inform or influence      thetical construct is a framework of assump-
treatment in any of the following circumstances:    tions, developed by theorists and researchers,
                                                    intended to enable subsequent observations to
• To clarify diagnostic possibilities and as-       be understood. Another term for construct is
  sess psychopathology.                             domain. For example, intelligence and personal-
• To generate insights about a client’s             ity are defined as constructs because neither ex-
  strengths or coping abilities.                    ists as a physical entity that can be directly
• To gather information for treatment               measured. Instead, behaviors or attributes con-
  planning.                                         sidered to be the result of or expression of intel-
• To understand a client’s lack of progress in      ligence or personality must be measured. There
  counseling.                                       is no irrefutable proof that intelligence or per-
• To determine whether a client meets eligi-        sonality per se exist within people, but there
  bility requirements for inclusion in a par-       are individual differences in people’s behavior
  ticular program. For example, a client may        that are measurable. Some of those differences
  be under consideration for a community-           are assumed to be the result of varying levels
  based group living arrangement that re-           and types of intelligence or personality.
  quires a minimum skill level in activities            All of those domains are presumed to exist
  of daily living. Using test data, a clinician     on a continuum. That is to say, whether we are
  may determine whether the client pos-             talking about a specific cognitive ability, a
  sesses the requisite level of independence        personality attribute, or symptoms of a diag-
  and remission of symptoms to be able to           nosable psychological disorder, there is no ab-
  benefit from the program.                         solute presence or absence of the attribute
                                                    being measured. The construct extroversion
   Counselors may administer and interpret          exemplifies this continuum. Extroversion
the tests with their own clients, may be the re-    refers to the extent to which an individual
ferral source and subsequent recipient of data      prefers frequent or constant social and inter-
gathered by other clinicians, or may conduct        personal contact, at one end of the continuum,
testing for individuals in counseling with          or solitary activities, at the other end of a con-
others. The information in this chapter is ap-      tinuum. Most people prefer some combination
plicable in all these circumstances, but the em-    of both, but even those individuals at the far
phasis is on integrating data from test scores      ends of the continuum would not be consid-
into treatment planning and process. Integra-       ered to have absolute absence or absolute
tion of test data into treatment is both an art     presence of the trait of extroversion.
and a science that involves incorporation of the        There are three other terms used fre-
client’s unique background data and observa-        quently in the context of standardized assess-
tions of the client’s behavior during the testing   ment. The term norm refers to a sample of
with test findings. This chapter is to be read      people on whom the test has been standard-
with the caution that competence in using test      ized. That standardization sample is referred
data in practice requires both knowledge of the     to as the norm group, meaning that test devel-
psychometric properties of the test and super-      opers have carefully researched patterns of
vised experience in its use in the clinical set-    responses that are common. When a test is ad-
ting. Using test data in clinical practice          ministered to a client, that client’s responses
without this background is unethical.               (raw scores) are compared to the responses of
                     15 • USING TEST DATA IN COUNSELING AND CLINICAL PRACTICE                    101

those people in the norm group, thus yielding       Campbell, & McGregor, 1988). Within each
a comparison of the client to the norm, which,      of those domains, there are numerous ways
theoretically, equates to typical or average        testing can be used to creatively enhance the
among the general population. The term valid-       diagnostic or treatment process.
ity refers to whether the test does, in fact,          Certainly, one traditional and valuable way
measure the construct the test developer was        that psychological test results have been used
trying to measure. Finally, reliability refers to   is to help confirm a diagnosis (though test
stability of test scores over time. In other        scores can never be the sole source of data for
words, when a test has high reliability, we can     a diagnosis). However, test scores can also be
be reasonably certain that if the same test         used in ways that do not emphasize diagnosis.
could be administered to the same person            An alternative approach is to describe a client’s
many times, his or her raw score would be ap-       traits, abilities, and symptoms, and to then con-
proximately the same every time. A test can         sider those descriptions and preferences in the
be reliable without necessarily being valid,        broader context of how to be most helpful to
but a valid test will always be reliable.           that person.
   Regardless of the particular construct the
test seems to measure, clinicians need answers
to the following questions before selecting any     Cognitive Ability Tests (Intelligence
particular measure:                                 and Achievement)

                                                    Following is a partial list of cognitive ability
• What is the evidence regarding the reliabil-      tests commonly encountered in a community
  ity and validity of test scores (i.e., does the   mental health setting:
  test measure the construct it purports to
  measure and does it do so consistently)?             Wechsler Intelligence Scale for Children,
  How much confidence can I place in the ac-           third revision (WISC-III) (Wechsler, 1991)
  curacy of the results?
                                                       Wechsler Adult Intelligence Scale, third re-
• What is the norm group for the test, and is
                                                       vision (WAIS-III) (Wechsler, 1997)
  it sufficiently comparable to my client to
  justify its use? Does it include adequate            Kaufman Assessment Battery for Children
  representation of the cultural group of my           (Kaufman & Kaufman, 1983)
  client? (See Chapter 40 for a discussion of          Kaufman Adolescent and Adult Intelli-
  multicultural assessment.)                           gence Test (Kaufman & Kaufman, 1993)
• Is my client able to cooperate with the test         Wechsler Individual Achievement Test
  administration process based on current              (Wechsler, 1992)
  physical, psychological, and intellectual
                                                       Wide Range Achievement Test—3 (Wilkin-
  characteristics?
                                                       son, 1993)
• How effectively can the test identify uncoop-
  erative, dishonest, or confused test takers?         Peabody Individual Achievement           Test
                                                       (Markwardt-Frederick, 1989)
                                                       Shipley Institute of Living Scale (Shipley &
TYPES AND APPLICATIONS OF TESTS                        Zachary, 1986)

Tests can be categorized by the domains                In the realm of cognitive ability testing,
(or constructs) they assess, such as cognitive      test scores may be used to inform a decision
ability, personality characteristics, career in-    about whether to include a client in some type
terests, academic achievement, learning dis-        of program. For instance, there may be a min-
abilities, and adaptive behavior. Cognitive         imum degree of auditory processing and at-
ability, personality, and career interest           tention necessary for a client to benefit from a
measures are commonly administered in               group therapy setting for a substance abuse
community mental health settings (Watkins,          problem. A cognitive ability test such as the
102     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

Shipley Institute of Living Scale (Shipley &          problem. Cognitive flexibility is necessary to
Zachary, 1986) might be used to determine             adapt to environmental stressors. Knowing
whether a client is demonstrating the mini-           that a client has difficulty with cognitive flex-
mum cognitive ability necessary. Similarly,           ibility can help a clinician to target expanding
cognitive ability testing might help a therapist      flexibility as an intermediate treatment goal
make an informed prediction about a client’s          to increase the potential for the client to deal
ability to benefit from some facet of treat-          effectively with environmental stressors.
ment, such as partial hospitalization. Con-              Data gathered from a client’s approach to
sider the following case example:                     the testing experience also has therapeutic
                                                      value. The behavioral observations made dur-
   Joe is a 35-year-old man diagnosed with Schizo-    ing testing can reveal how clients respond to
   phrenia. He has lived with his parents since his   environmental ambiguity, time pressure, frus-
   first psychotic break 15 years ago. Joe’s case     trations in problem solving, and risks of making
   manager has been insistent that he participate     erroneous choices. They can also inform us
   in a partial hospitalization program, despite      about the client’s persistence in challenging
   previous failed attempts at such groups. Joe has   tasks and level of self-acceptance. All of these
   historically complained that he did not find the   characteristics have direct bearing on a person’s
   partial program beneficial. On standardized        functioning in a work setting, in interpersonal
   measures, Joe demonstrates markedly elevated       relationships, and as part of a community.
   scores on tests of verbal functioning and          Thus, astute clinicians can glean valuable infor-
   slightly below average auditory/motoric func-      mation from a cognitive ability test far beyond
   tioning. Despite his serious psychiatric diagno-   the obvious data about how many vocabulary
   sis, his ability level is such that the partial    words are known or how many novel arithmetic
   program is not only unhelpful, but might actu-     problems are solved correctly.
   ally be detrimental to the process of his learn-
   ing to manage his illness.
                                                      Personality Tests

    For a client who has scored markedly higher       Personality tests measure client traits and
or markedly lower on a cognitive ability test in      states related to intrapsychic and interper-
comparison to other group members, the for-           sonal functioning. Personality tests are di-
mat of the group might be either too simplistic       vided into two categories: objective and
or too complex. In either case, that client might     projective formats. Objective personality tests
experience a degree of frustration or sense of        have limited response options, such as true or
failure that could be detrimental to the treat-       false. Projective tests use neutral stimuli such
ment process, as Joe’s case illustrates. Cognitive    as inkblots and then ask the test taker to gen-
ability testing can also give clinicians data         erate elaborate responses. Examples of projec-
about therapeutic approaches that will maxi-          tive instruments include the Rorschach Inkblot
mize client’s integration of new information.         Test (Rorschach, 1951) and the Thematic Ap-
For instance, a client’s test scores may reveal       perception Test (Murray, 1943). Because of
the client’s preferred learning style in per-         space limitations, this chapter focuses exclu-
forming verbal, auditory tasks, or visual, mo-        sively on objective personality tests. Com-
toric tasks. Clinicians can use such information      monly used objective personality assessment
to design future interventions in counseling to       instruments include:
improve the efficiency and effectiveness of in-
terventions.                                             Millon Clinical Multiaxial         Inventory
    Cognitive testing can also generate infor-           (MCMI) (Millon, 1987)
mation to assist clinicians in appreciating a            Minnesota Multiphasic Personality Inven-
client’s level of cognitive flexibility, the rapid-      tory, second revision (MMPI-2) (Butcher,
ity with which a person is able to switch men-           Dahlstrom, Graham, Tellegen, & Kaemmer,
tal sets and generate alternative solutions to a         1989)
                     15 • USING TEST DATA IN COUNSELING AND CLINICAL PRACTICE                       103

   Minnesota Multiphasic Personality Inven-         NEO PI-R [Costa & McCrae, 1992]; 16PF [Cat-
   tory,  Adolescent    version   (MMPI-A)          tell et al.,1993]); others identify symptoms
   (Butcher, Williams, Graham, Archer, Telle-       and suggest possible DSM-IV diagnoses to
   gen, Ben-Porath, & Kaemmer, 1992)                consider (MMPI-2 [Butcher et al., 1989]; PAI
   Neuroticism Extroversion Openness Per-           [Morey, 1991]). The PAI, for example, includes
   sonality Inventory—Revised (NEO PI-R)            norms for specific diagnostic categories, in-
   (Costa & McCrae, 1992)                           cluding anxiety disorders, thought disorders,
                                                    mood disorders, antisocial personality disor-
   Personality Assessment Inventory (PAI)
                                                    ders, and substance abuse.
   (Morey, 1991)
                                                       When using a multiscaled personality in-
   Sixteen Personality Factor questionnaire         ventory such as the MMPI-2, clinicians can
   (16PF) (Cattell, Cattell, & Cattell, 1993)       discuss with their client how specific scores/
                                                    traits not directly connected to the presenting
    In addition to the information personality      problems still contribute to distress. Con-
test scores provide regarding intrapsychic dy-      versely, counselors can help clients take ad-
namics, scores can generate information re-         vantage of other traits identified by the test
garding a client’s functioning in social and        that can be assets to recovery. Consider the fol-
intimate relationships. Sometimes, questions        lowing case example.
about interpersonal functioning arise in
forensic settings where a typical referral             Bob is referred to counseling for panic attacks
question might be “What can the test reveal            and demonstrates a high level of anxiety, with
about the likelihood client X will again assault       an onset following being passed over for a pro-
her child?” or “What can the test reveal about         motion. His NEO PI-R (Costa & McCrae, 1992)
the extent to which client Y actually intended         profile reveals that he tends to use a rigid cog-
to harm someone when he lost his temper?”              nitive style and is extremely competitive (al-
Data from personality inventories will assist          though his competitiveness is mainly within
in making subsequent decisions regarding               himself, setting extremely high standards for
child custody or whether incarceration is an           himself ), which seem to contribute substan-
appropriate consequence for the client. Again,         tially to decreased effectiveness in his work
it is crucial to remember that, because of the         performance. However, despite his rigidity, he
limits of reliability and validity, test findings      also demonstrates cooperativeness and agree-
cannot ethically be used as the sole criterion         ableness. After working on cognitive restruc-
for decision making about these important              turing and assertiveness in counseling, he is
matters. Multiple sources of data confirming           able to discuss the promotion situation with his
the test finding must be available as well             boss and, owing to his high level of coopera-
(Welfel, 1998).                                        tion, receives a favorable response from his boss
    Information about a person’s intrapersonal         about a new position.
dynamics can illuminate the connection be-
tween conflicting emotions within an indi-             Finally, test results showing a client’s need
vidual and thus why certain emotional               for external structure, level of anxiety about
symptoms are being generated and how per-           disclosing personal information, and degree of
sonality attributes and behavior are maintain-      autonomy and initiative can be used to help se-
ing the symptoms. Several of the personality        lect appropriate treatment strategies. For ex-
inventories incorporate validity scales, which      ample, a client who experiences anxiety or
yield information about test takers’ inclina-       discomfort in ambiguous interpersonal situa-
tion to either emphasize or de-emphasize            tions may find an unstructured experiential
their experiencing of their symptoms.               counseling approach less comfortable than a
    Some of the above listed instruments are        directive, behavioral approach. Much has been
used primarily to describe relative degrees of      written recently about rationales for choosing
personality traits such as extroversion (e.g.,      treatment strategies, with emphasis on using
104     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

empirically validated treatments (Chambless            Symptom cluster instruments also have ap-
et al., 1998; Seligman, 1998). Nevertheless, per-   plications in research on treatment efficacy,
sonal preferences and characteristics of the        particularly in differentiating between those
client are also important variables to consider     participants with the disorder and those with-
in the treatment process. For instance, out-        out it. One reliable way to make that differenti-
come research suggests that, generally, the         ation is to use an instrument developed
most efficacious treatment for a specific pho-      specifically to confirm a particular diagnosis
bia is an exposure and response-prevention          (along with other data, of course).
treatment protocol. However, if a clinician has
access to personality inventory information,
                                                    CLIENT FEEDBACK AS PART OF THE
he or she may find test scores suggesting that
                                                    THERAPY PROCESS
the client would feel more comfortable in an al-
ternative treatment approach. In that case, the
                                                    Active client involvement in the testing pro-
clinician may find some creative way to inte-
                                                    cess is important. Initially, a clinician who is
grate an empirically valid treatment approach
                                                    arranging for a client to be tested must hon-
with the client’s preferred approach. Such in-
                                                    estly communicate to the client, in language
tegration would be highly respectful of the
                                                    understandable to the client, what is hoped to
client and increase the probability for benefit
                                                    be gained from the testing. If the client has
from therapy.
                                                    been referred from another professional, it is
                                                    important to begin the assessment process by
Symptom Cluster Tests
                                                    asking the client to explain his or her under-
There are many instruments developed to as-         standing of why the testing referral came
sess presence and intensity of particular           about. Client understanding of the evaluation
forms of distress. A few examples include:          process is important for two reasons. First, the
                                                    greatest likelihood of getting valid, usable
   Beck Depression Inventory, second revi-          client responses occurs when clients clearly
   sion (Beck, Steer, & Brown, 1996)                understand the importance of cooperating
   Trauma Symptom Inventory (Briere, 1995)          with testing and believe that a concerted effort
   State-Trait Anger Expression Inventory           will be beneficial to them. Second, as part of
   (Spielberger, 1983)                              the ordinary ethical obligation of informed
                                                    consent, the clinician needs to thoroughly dis-
   These instruments assist clinicians in rul-      cuss the testing process.
ing in or out particular disorders in the case of      In general, beyond the specific test scores
a questionable differential diagnosis. For ex-      and results obtained, the testing process can
ample, a client may be complaining of a high        be used to enhance both the therapeutic al-
degree of anxiety, yet on the Beck Depression       liance and client responsiveness to therapy.
Inventory, she is endorsing many items indica-      Test data can help clinicians respond more em-
tive of a clinical depression. This finding         pathetically to clients, thereby increasing rap-
may have bearing on the type of medication          port and client motivation to continue
prescribed and the type of treatment plan de-       therapeutic work. In addition, clients may find
veloped.                                            tests results confirming of their internal expe-
   Second, instruments that focus on specific       rience and may thereby experience relief to
symptoms are especially valuable in quantify-       find that their level of symptoms is in the clin-
ing the degree of client response to treatment.     ically significant range. Such scores can lend
For example, a therapist can administer the         credence to their suffering, and clients may ex-
Beck Depression Inventory 2 (Beck et al.,           perience a sense of validation. One adult
1996) at the beginning of treatment and peri-       client, Sue, was vastly relieved to receive a di-
odically during treatment to evaluate changes       agnosis of Attention-Deficit Disorder (ADD),
in depressive symptoms.                             because it enabled her to “make sense” of the
                       15 • USING TEST DATA IN COUNSELING AND CLINICAL PRACTICE                            105

academic troubles she had experienced her en-            Butcher, J.N., Dahlstrom, W.G., Graham, J.R., Telle-
tire life. Prior to this evidence, she had con-              gen, A., & Kaemmer, B. (1989). Minnesota Mul-
cluded that she was not “very smart,” but the                tiphasic Personality Inventory–2 (MMPI-2).
diagnosis of ADD enabled her to realize that                 Minneapolis: University of Minnesota Press.
her symptoms were instead the result of a neu-           Butcher, J.N., Williams, C.L., Graham, J.R., Archer,
                                                             R.P., Tellegen, A., Ben-Porath, Y.S., & Kaem-
ropsychological condition. Thus, the test find-
                                                             mer, B. (1992). Minnesota Multiphasic Personality
ings, coupled with other evidence of ADD, led
                                                             Inventory for Adolescents: Manual for administra-
to a breakthrough in counseling for Sue. Per-                tion, scoring, and interpretation. Minneapolis:
haps adding to the “aha” experience for her                  University of Minnesota Press.
was the counselor’s willingness to focus on              Cattell, R.B., Cattell, A.K.S., & Cattell, H.E.P.
how the disorder influenced the development                  (1993). Sixteen Personality Factor Questionnaire
of her self-image and the parts of that self-                (5th ed.). Champaign, IL: Institute for Person-
image she now hoped to change.                               ality and Ability Testing.
                                                         Chambless, D.L., Baker, M.J., Baucom, D.H., Beut-
                                                             ler, L.E., Calhoun, K.S., Crits-Christoph, P.,
Sources for Additional Information
                                                             Daiuto, A., DeRebeis, R., Detweiler, J.,
For a broad-brush description of many differ-                Haaga, D.A.F., Johnson, S.B., McCurry, S.,
ent types of tests, readers are referred to text-            Mueser, K.T., Pope, K.S., Sanderson, W.C.,
books on assessment such as The Handbook of                  Shoham, V., Stickle, T., Williams, D.A., &
Psychological Assessment (Groth-Marnat, 1999),               Woody, S.R. (1998). Update on empirically
                                                             validated therapies, II. The Clinical Psycholo-
Psychological Testing (Anastasi & Urbina, 1997),
                                                             gist, 51(1), 3 –16.
and Tests and Assessment (Walsh & Betz, 1995).
                                                         Costa, P.I., & McCrae, R.R. (1992). Neuroticism Ex-
Additionally, many books are available that                  troversion Openness Personality Inventory–
help readers learn the subtleties of test inter-             Revised. Odessa, FL: Psychological Assess-
pretation for particular instruments, such as                ment Resources.
The Revised NEO Personality Inventory: Clinical          Groth-Marnat, G. (1999). Handbook of psychological
and Research Applications (Piedmont, 1998), In-              assessment (3rd ed.). New York: Wiley.
telligent Testing with the WAIS-III (Kaufman,            Kaufman, A.S. (1996). Intelligent testing with the
1996), Essentials of WISC-III and WPPSI-R As-                WAIS-III. New York: Wiley.
sessment (Kaufman & Lichtenberger, 2000), and            Kaufman, A.S., & Kaufman, N.L. (1983). Kaufman
An Interpretive Guide to the Personality Assess-             Assessment Battery for Children. Circle Pines,
                                                             MN: American Guidance Service.
ment Inventory (Morey, 1996).
                                                         Kaufman, A.S., & Kaufman, N.L. (1993). Kaufman
    Another source of training and developing
                                                             Adolescent and Adult Intelligence Test. Circle
expertise in the use of clinical instruments is              Pines, MN: American Guidance Service.
workshops or seminars. There are often adver-            Kaufman, A.S., & Lichtenberger, E.O. (1999). Essen-
tisements in professional publications such as               tials of WAIS-III assessment. New York: Wiley.
the APA Monitor or the ACA Counseling Today              Kaufman, A.S., & Lichtenberger, E.O. (2000). Essen-
for training workshops, sometimes presented                  tials of WISC-III and WPPSI-R assessment. New
by the author of a test or by representatives of             York: Wiley.
a test publishing company.                               Markwardt-Frederick, C., Jr. (1989). Peabody Indi-
                                                             vidual Achievement Test-Revised. Circle Pines,
                                                             MN: American Guidance Services.
References
                                                         Millon, T. (1987). Manual for the Millon Clinical Mul-
Anastasi, A., & Urbina, S. (1997). Psychological test-       tiaxial Inventory (MCMI). Minneapolis: Na-
     ing (7th ed.). Upper Saddle River, NJ: Prentice-        tional Computer Systems.
     Hall.                                               Morey, L. (1991). Personality Assessment Inventory.
Beck, A.T., Steer, R.A., & Brown, G. (1996). Beck De-        Odessa, FL: Psychological Assessment Re-
     pression Inventory (2nd ed.). San Antonio, TX:          sources.
     Psychological Corporation.                          Morey, L. (1996). An interpretive guide to the Person-
Briere, J. (1995). Trauma Symptoms Inventory. Odessa,        ality Assessment Inventory. Odessa, FL: Psycho-
     FL: Psychological Assessment Resources.                 logical Assessment Resources.
106      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

Murray, H.A. (1943). Thematic Apperception Test           Watkins, C.E., Jr., Campbell, V.L., & McGregor, P.
     manual. Cambridge, MA: Harvard University                (1988). Counseling psychologists’ uses of the
     Press.                                                   opinions about psychological tests: A contem-
Piedmont, R.L. (1998). The Revised NEO Personality            porary perspective. The Counseling Psycholo-
     Inventory: Clinical and research applications.           gist, 16, 476 – 486.
     New York: Plenum Press.                              Wechsler, D. (1991). The Wechsler Intelligence Scales
Rorschach, H. (1951). Rorschach Inkblot Test. Psy-            for Children–III. New York: Psychological Cor-
     chodiagnostics: A diagnostic test based on percep-       poration.
     tion. New York: Grune & Stratton.                    Wechsler, D. (1992). Wechsler Individual Achievement
Seligman, L. (1998). Selecting effective treatments: A        Test. New York: Psychological Corporation.
     comprehensive, systematic guide to treating mental   Wechsler, D. (1997). Wechsler Adult Intelligence Scale
     disorders (Rev. ed.). San Francisco: Jossey-Bass.        (3rd ed.). New York: Psychological Corpora-
Shipley, W.C., & Zachary, R.A. (1986). Shipley Insti-         tion.
     tute of Living Scale. Los Angeles: Western Psy-      Welfel, E.R. (1998). Ethics in counseling and psy-
     chological Services.                                     chotherapy: Standards, research, and emerging is-
Spielberger, C.D. (1983). Manual for the State-Trait          sues. Pacific Grove, CA: Brooks/Cole.
     Anxiety Inventory (Form-Y). Palo Alto, CA:           Wilkinson, G.S. (1993). Wide Range Assessment
     Mind Garden.                                             Test 3. Wilmington, DE: Jastak Associates-
Walsh, W.B., & Betz, N.E. (1995). Tests and assessment        Wide Range.
     (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall.




                    TREATING ANXIETY
      16            DISORDERS IN ADULTS


                    Paul F. Granello and Darcy Haag Granello



Anxiety is an emotional and physiological                 function. More than 16 million Americans
state that all people feel and that can be                between the ages of 15 and 24 have anxiety
either normal or pathological. Anxiety can                disorders (National Institute of Mental
be defined as a feeling of unpleasant appre-              Health [NIMH], 1999), and an estimated 80%
hension typically accompanied by bodily                   of persons diagnosed with anxiety disorders
sensations such as a tightness in the chest, a            experience panic attacks.
feeling of choking, perspiring, and trembling                Several theories have been generated to
or shaking. Often, anxious individuals feel               explain the causes of pathological anxiety.
restless or confused or think they are not in             Cognitive-behavioral theorists believe that
control or even that they are dying (APA,                 when a stimulus is observed, perceived, or
2000). Normal anxiety serves an adaptive                  otherwise experienced as frightening, future
function if it motivates the individual to                threats of that stimulus are also perceived
behave in a way that forestalls danger. Anxi-             with apprehension or avoidance (Seligman,
ety is pathological when, due to its intensity            1998). Psychoanalytic theory suggests
or duration, it impedes the client’s ability to           that anxiety is a warning to the ego that
                                       16 • TREATING ANXIETY DISORDERS IN ADULTS                 107

unacceptable unconscious material is press-        the research on Obsessive-Compulsive Dis-
ing for expression and that the ego must take      order and Posttraumatic Stress Disorder, al-
action, usually in the form of a defense           though these disorders also have many rigor-
mechanism to cope (Kaplan & Sadock, 1998).         ous studies associated with them. Research to
Existential theory is useful in explaining         date on generalized anxiety disorder has
“free-floating” anxiety, often associated          demonstrated only modest treatment gains,
with generalized anxiety disorder. This form       and thus the choice of intervention remains
of anxiety is thought to stem from an indi-        more open to question for this disorder than
vidual’s sense of purposelessness and mean-        for any of the other anxiety disorders.
inglessness in life (Savolaine & Granello,
2000). Finally, biological theories suggest
that the autonomic nervous system, limbic          GENERAL TREATMENT APPROACH
system, and regions of the cerebral cortex
may have dysfunctions in relation to patho-        Although the treatment for the various types
logical anxiety. Specific neurotransmitters,       of anxiety disorders differs, there are some
such as norepinephrin, y-aminobutric acid          generalized treatment approaches that have
(GABA), and serotonin, have been linked to         been found to be successful across the spec-
anxiety (Kaplan & Sadock, 1998).                   trum of anxiety disorders. In their landmark
   The Diagnostic and Statistical Manual,          meta-analysis, Smith, Glass, and Miller (1980)
fourth edition, text revised (DSM-IV-TR), of       found effect sizes for the treatment of anxiety
the American Psychiatric Association (APA,         disorders to be 1.78 for cognitive-behavioral
2000) names the following under the heading        approaches, 1.67 for cognitive approaches
of anxiety disorders: Panic Disorder with          alone, and 1.12 for behavioral approaches
and without Agoraphobia, Specific Phobia,          alone. Unlike the null hypothesis, which sim-
Social Phobia, Obsessive-Compulsive Disor-         ply measures whether or not a relationship ex-
der, Posttraumatic Stress Disorder, Acute          ists, effect sizes measure the strength of a
Stress Disorder, Generalized Anxiety Disor-        relationship, with higher numbers indicating
der, Anxiety Disorder Due to a Medical Con-        greater strength. All of these effect sizes are
dition, Substance-Induced Anxiety Disorder,        considered large (Stevens, 1992). Subsequent
and Anxiety Disorder NOS. These disorders          research has supported the meta-analytic re-
are classified together because anxiety is a       sults on the treatment of anxiety disorders
significant presenting symptom in all of           (Barlow, Esler, & Vitali, 1998; Franklin & Foa,
them. However, each disorder responds dif-         1998; Keane, 1998). There is growing support
ferently to pharmacological interventions,         in the research for the use of pharmacological
leading researchers to suspect that they are       interventions as an adjunct to psychosocial
really a heterogeneous group of disorders          treatments, particularly for severe cases when
(Kaplan & Sadock, 1998).                           debilitating anxiety limits the initial success of
                                                   psychosocial interventions (NIMH, 1999). For
                                                   all the anxiety disorders, a medical referral is
STATUS OF THE AVAILABLE RESEARCH                   strongly encouraged to rule out a medical con-
                                                   dition that might mimic the symptoms of anxi-
Anxiety disorders are some of the most well-       ety (Beamish, Granello, Granello, McSteen, &
researched psychiatric disorders, and several      Stone, 1997).
of them, particularly Panic Disorder and the
phobias, have large bodies of rigorous efficacy
                                                   SPECIFIC TREATMENT
studies associated with their treatment. The
                                                   RECOMMENDATIONS BY DISORDER
National Institute of Health (NIH) issued a
consensus statement for the treatment of panic
                                                   Panic Disorder with and without Agoraphobia
disorder in 1991, the first psychological disor-
der to be included in a consensus statement of     Panic Disorder is one of the most common men-
this type. There is less consensus arising from    tal disorders for which people seek treatment,
108     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

with up to 4 million people, or 1.5% of the         interventions, but overreliance on medica-
U.S. population, meeting the criteria for this      tion can limit the success of psychother-
disorder. Panic Disorder is characterized by        apy by artificially lowering anxiety levels,
the existence of panic attacks that are not         which rebound when medication is with-
cued by external stimuli. These panic attacks       drawn (Beamish et al., 1996).
can lead to the development of agoraphobia,
and thus panic disorder can occur without
(PD) or with agoraphobia (PDA). There is         Specific Phobia and Social Phobia
high comorbidity with mood disorders (50%
                                                 Lifetime prevalence for specific phobias is
to 65%; Agras, 1993) and substance abuse
                                                 11%, with significant gender differences
disorders (15%; Barlow & Shear, 1988), and
                                                 (females = 16%, males = 7%) (Kessler et al.,
up to 20% of individuals with panic disorder
                                                 1994). Specific phobias, although very com-
attempt suicide (Agras, 1993).
                                                 mon overall, tend to be distinct. That is,
   Treatment interventions that have been
                                                 when a client presents with a specific phobia,
supported by the research (Beamish et al.,
                                                 it is unlikely that other Axis I or Axis II diag-
1997; NIH, 1991) include:
                                                 noses will be comorbid. Social phobia is very
Cognitive therapy                                common and is the third most prevalent of all
                                                 mental disorders, exceeded only by Major
• Cognitive restructuring to counter the cat-
                                                 Depressive Disorder and alcohol dependence.
  astrophic misinterpretations of bodily sen-
                                                 Comorbidity of social phobia and Axis I
  sations or psychological experiences that
                                                 disorders is common, most often with Agora-
  occur during panic attacks.
                                                 phobia (45%), alcohol abuse (19%), major de-
• Focused cognitive therapy to recreate panic
                                                 pression (17%), drug abuse (13%), Dysthymia
  symptoms in the therapy session and then
                                                 (13%), and Obsessive-Compulsive Disorder
  reattribute the physical sensations to the
                                                 (11%) (Schneier, Johnson, Hornig, Liebowitz,
  proper causes.
                                                 & Weissman, 1992). Additionally, up to 70%
• Panic education as an adjunct to inform
                                                 of persons who meet the criteria for social
  clients about the nature of panic disorder.
                                                 phobia also meet the criteria for Avoidant
Behavioral therapy                               Personality Disorder.
                                                     Treatment interventions that have been
• Best when combined with cognitive therapy.
                                                 supported in the research include (Barlow
• Breathing retraining, biofeedback, stress
                                                 et al., 1998):
  inoculation training, meditation, applied
  relaxation ( but not progressive relax-
  ation), and graduated exposure (to pre-        Behavioral therapy
  vent the development of agoraphobia in         • Exposure therapy: There is broad consen-
  PD clients or to treat agoraphobia in PDA        sus in the research literature for treatment
  clients).                                        of specific phobias that is exposure-based,
                                                   particularly in vivo exposure. Many clients
Family therapy                                     show improvement after only one to three
• Less supported by the research, but proba-       sessions. High therapist involvement is a
  bly an important component of PDA, as            key component of this treatment.
  family members often engage in enabling        • Imaginal exposure has been shown to be ef-
  behaviors that allow the agoraphobia to          fective in reducing fear when in vivo expo-
  continue.                                        sure is unavailable, but in vivo is preferred.
                                                 • Hypnosis has received some support in the
Pharmacological interventions                      research literature (Kaplan & Sadock,
• Tricyclic antidepressants, MAOIs, ben-           1998).
  zodiazepines, and SSRIs have all been          • Relaxation techniques are particularly im-
  used in conjunction with psychological           portant for the treatment of social phobia.
                                       16 • TREATING ANXIETY DISORDERS IN ADULTS              109

Cognitive therapy                                    reached. The use of Rational Emotive Ther-
• Cognitive restructuring and social skills          apy (e.g., understanding the realistic con-
  training are important components for the          sequences of not engaging in rituals) and
  treatment of social phobia.                        Socratic questioning to challenge clients’
                                                     dysfunctional beliefs appear to be an im-
Pharmacological interventions                        portant component of treatment (Franklin
(Roy-Byrne & Cowley, 1998)                           & Foa, 1998).
• Pharmacological treatments have not been         Family therapy
  proven effective for the treatment of spe-
  cific phobias.                                   • Because of the high degree of family dys-
• For the treatment of social phobia, there          function and marital discord associated
  has been support for MAOIs and SSRIs.              with OCD, family therapy is considered an
  Benzodiazepines also have demonstrated             important adjunct to therapy (Amir, Fresh-
  some success, but their use is complicated         man, & Foa, 2000).
  by high rates of substance abuse comorbid-       Pharmacological interventions
  ity with social phobia.
                                                   • Drugs may be an important adjunct to treat-
                                                     ment, particularly for clients for whom psy-
Obsessive-Compulsive Disorder (OCD)                  chotherapy or behavioral therapy alone has
                                                     been ineffective. Pharmacological interven-
The prevalence rate for OCD is 2.5% in adults,
                                                     tions appear to be more successful in treat-
and it appears that this disorder occurs at ap-
                                                     ing the compulsions than the obsessions.
proximately that rate in children and adoles-
                                                     With OCD, there is often a medication lag
cents (Valleni-Basile et al., 1994). Because of
                                                     of up to two months before any noticeable
the nature of this disorder, clients with severe
                                                     improvement, and thus medication trials
OCD often have difficulty maintaining em-
                                                     should last 6 to 12 months before attempts
ployment and have extreme dysfunctions in
                                                     are made to taper off the medication (Ka-
their marital and interpersonal relationships
                                                     plan & Sadock, 1998).
(Franklin & Foa, 1998).
                                                   • The tricyclic antidepressant clomipramine
   Treatment interventions that have been
                                                     (Anafranil) has become the standard med-
supported in the research include:
                                                     ication for OCD. Recent research has sup-
                                                     ported the efficacy of SSRIs, although
Behavioral therapy
                                                     these have not been as extensively studied
• Behavioral intervention is considered the          with this population, and no research ex-
  “gold standard” for treatment of OCD and           ists to suggest that they are more effective
  has received much empirical support in             for OCD than clomipramine (den Boer,
  highly controlled efficacy studies (e.g.,          Bosker, & Slaap, 2000).
  Franklin, Abramowitz, Kozak, Levitt, &
  Foa, 2000). Supported interventions in-
  clude in vivo exposure, imaginal exposure,       Posttraumatic Stress Disorder (PTSD) and
  ritual prevention, and systematic desensi-       Acute Stress Disorder (ASD)
  tization to the source of the anxiety (e.g.,     Prevalence rates for PTSD and ASD range
  germs or dirt).                                  from 1% to 14% in various studies. This broad
                                                   range can be accounted for by fluctuations
Cognitive therapy                                  in the occurrences and nature of disasters
• Cognitive interventions, in conjunction          that affect large populations (e.g., bombings,
  with behavioral techniques, appear to be         earthquakes) and traumatic events that affect
  supported by the research literature, al-        individuals (e.g., rapes, assaults). PTSD has
  though this is a relatively new area of          significant comorbidity with other Axis I dis-
  study and no consensus has yet been              orders, particularly alcohol abuse (70%) and
110     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

depression (68%), as well as Axis II disorders     significant treatment success (Meltzer-Brody,
(26%) (Roth & Fonagy, 1996). ASD is diag-          Connor, Churchill, & Davidson, 2000). Other
nosed when the symptoms last for less than         pharmacological interventions that have re-
one month; PTSD is diagnosed when the              ceived empirical support include tricyclic an-
symptoms last for more than one month.             tidepressants, MAOIs, and benzodiazepines
   Treatment interventions that have been          (these should be used with caution, given the
supported by the research include:                 high rates of comorbidity with substance
                                                   abuse) (Yehuda, Marshall, & Giller, 1998).
Critical incident stress debriefing (CISD)
• As soon as possible after the trauma, CISD
                                                 Generalized Anxiety Disorder (GAD)
  is recommended to try to prevent the devel-
  opment of PTSD. It is intended to help         GAD is characterized by excessive worry
  the client learn to tolerate and process the   about several circumstances on more days
  trauma, express feelings surrounding the       than not for a period of more than six months
  trauma, and learn increased control and        (APA, 2000). GAD is a chronic disorder that
  coping (see Carlier, 2000).                    may have biological and characterological
                                                 bases that are not completely amenable to
Behavioral therapy                               psychotherapy (Barlow et al., 1998). GAD has
• Systematic     desensitization   (gradual      a prevalence of 5.1% in the general population
  exposure to reminders of the trauma),          and is twice as common in women as men.
  habituation, and anxiety management            More than 90% of clients with GAD have a
  ( biofeedback, relaxation) (Tarrier, Som-      lifetime history of the disorder (Roy-Byrne &
  merfield, Pilgrim, & Humphreys, 1999).         Cowley, 1998). Although research to date has
                                                 not uncovered a treatment that is effective in
Cognitive therapy
                                                 eliminating the symptoms of GAD, several in-
• To modify cognitive distortions about the      terventions have shown moderate success in
  trauma (e.g., self-blame, impact of the        reducing the severity of the symptoms.
  trauma).                                           Treatments that have been demonstrated
• Stress inoculation training (thought stop-     to show improvement include:
  ping, guided self-dialogue) (Keane, 1998).
                                                 Cognitive-behavioral therapy (CBT) (Barlow
Family therapy                                   et al., 1998)
• This is less supported by the research, but    • CBT has been shown to be more effective
  may be helpful in sustaining relationships       than analytic, nondirective, or relaxation
  through acute symptom periods.                   training, with significant improvements
                                                   for up to 75% of clients, with continued
EMDR (eye movement desensitization and
                                                   improvements at six-month follow-up.
reprocessing) (Shapiro, 1995)
                                                 • Behavioral therapy alone (e.g., exposure, re-
• The pairing of kinesthetic stimulation,          laxation, biofeedback) is not as effective as
  such as eye movement, with recall of the         when combined with a cognitive component.
  stressor. (This technique has been sup-
                                                 Pharmacological interventions
  ported primarily through case studies, al-
  though one efficacy study demonstrated         • Some success has been shown with the fol-
  improvement that was superior to biofeed-        lowing medications, all used in conjunction
  back for PTSD.)                                  with psychological interventions: benzodi-
                                                   azepines (Roth & Fonagy, 1996); buspirone
Pharmacological interventions                      (reduces the cognitive anxiety symptoms to
• No specific class of medications has been        a greater extent than the physical symp-
  demonstrated to be the treatment of choice,      toms; Feighner & Cohn, 1989); and antide-
  although SSRIs, particularly fluoxetine, are     pressants (imipramine or SSRIs; den Boer
  gaining in popularity and have demonstrated      et al., 2000).
                                              16 • TREATING ANXIETY DISORDERS IN ADULTS                      111

SUMMARY                                                    den Boer, J.A., Bosker, F.J., & Slaap, B.R. (2000).
                                                               Serotonergic drugs in the treat ment of de-
Anxiety disorders are some of the most                         pressive and anxiety disorders. Human Psy-
common clinical mental health diagnoses,                       chopharmacology Clinical and Experimental, 15,
and there is a substantial body of research                    315 –336.
                                                           Feighner, J.P., & Cohn, J.B. (1989). Analysis of indi-
relating to their treatment. In general, the re-
                                                               vidual symptoms in generalized anxiety: A
search supports a cognitive-behavioral ap-
                                                               pooled, multistudy, double-blind evaluation
proach to treatment, although this is less                     of buspirone. Neuropsychobiology, 21, 124 –130.
supported for Generalized Anxiety Disorder.                Franklin, M.E., Abramowitz, J.S., Kozak, M.J.,
Many different types of pharmacological in-                    Levitt, J.T., & Foa, E.B. (2000). Effectiveness of
terventions also have been demonstrated to                     exposure and ritual prevention for obsessive-
be effective in the treatment of anxiety, and                  compulsive disorder: Randomized compared
the mental health practitioner should work                     with nonrandomized samples. Journal of Con-
closely with the client’s physician in the                     sulting and Clinical Psychology, 68, 594 –602.
treatment of these cases.                                  Franklin, M.E., & Foa, E.B. (1998). Cognitive-behav-
                                                               ioral treat ments for obsessive-compulsive dis-
                                                               order. In P.E. Nathan & J.M. Gorman (Eds.), A
                                                               guide to treatments that work (pp. 339–357).
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Barlow, D.H., Esler, J.L., & Vitali, A.E. (1998). Psy-         U., & Kendler, K.S. (1994). Lifetime and 12-
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Barlow, D.H., & Shear, M.K. (1988). Panic disorder:            Davidson, J.R.T. (2000). Symptom-specific ef-
     Foreword. In A.J. Frances & R.E. Hales (Eds.),            fects of f luoxetine in post-traumatic stress
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Beamish, P.M., Granello, D.H., Granello, P.F., Mc-         Nathan, P.E., & Gorman, J.M. (1998). A guide to
     Steen, P., & Stone, D. (1997). Emerging stan-             treatments that work. New York: Oxford Uni-
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     782–791.                                                      /085_statement.ht m




                      DIAGNOSIS AND
       17             TREATMENT OF ADULT
                      DEPRESSIVE DISORDERS


                      Gary G. Gintner


One in five Americans will experience a clini-                Psychiatric Association [APA], 1994). According
cally significant episode of depression some-                 to the World Health Organization, depression is
time in his or her lifetime (American                         the fourth leading cause of disability-adjusted
                  17 • DIAGNOSIS AND TREATMENT OF ADULT DEPRESSIVE DISORDERS                        113

life years and premature death (Murray &             include psychotic features, hopelessness, a
Lopez, 1996). The extent of disability is directly   past attempt, access to lethal means, and poor
related to the severity of the depression (Max-      social support (APA, 2000). Inventories such
men & Ward, 1995). In this regard, both antide-      as the Beck Depression Inventory (Beck, 1976)
pressant medications and psychotherapy have          and the Hamilton Rating Scale (Hamilton,
been shown to be effective interventions for         1960) can be quite useful in assessing depres-
treating depression and reversing its disabling      sive symptomatology. These inventories can
consequences (APA, 2000).                            be readministered periodically to evaluate
    This chapter addresses two major issues in       therapeutic progress.
the treatment of adult depression. First, diag-      Differential Diagnosis. Common rule-out condi-
nostic issues are discussed relative to accu-        tions that can induce depressive symptoms in-
rately diagnosing depressive disorders and           clude certain medical conditions, medication
their common comorbid conditions. Second,            side effects, substance use, bereavement, and
established practice guidelines are reviewed         certain other psychiatric disorders. Medical
as a way of selecting empirically supported          conditions to consider include endocrine prob-
treatments. Although psychosocial treat-             lems (e.g., hypothyroidism and diabetes),
ments are emphasized, the role of somatic            chronic infections, strokes, and neurological
treatments such as antidepressant medica-            disorders (e.g., Parkinson’s disease; Gintner,
tions also is discussed.                             1995). Depressive symptoms can also be caused
                                                     by medications such as antihypertensives (e.g.,
                                                     reserpine, beta blockers, and mytheldopa),
DIAGNOSTIC ISSUES                                    hormone-enhancing drugs (e.g., oral contracep-
                                                     tives, estrogen replacement therapy, and
Major Depressive Disorder (MDD) and Dys-             steroids), benzodiazapines (e.g., Xanax), and
thymic Disorder are the two principle depres-        pain medications (Maxmen & Ward, 1995).
sive disorders listed in the Diagnostic and             A variety of substances can induce depres-
Statistical Manual of Mental Disorders, fourth       sive symptoms as a result of prolonged use or
edition (DSM-IV-TR; APA, 2000). In this sec-         withdrawal. Probably the most important to
tion, each disorder is examined with regard          rule out is alcohol abuse or dependence (APA,
to symptom presentation, differential diagno-        2000). In fact, it takes at least four to six weeks
sis, range of subtypes, and common co-occur-         of abstinence for alcohol-induced depressive
ring disorders.                                      symptoms to clear (APA, 2000).
                                                        Another important rule-out is bereave-
                                                     ment, which is the reaction to the death of a
Major Depressive Disorder
                                                     loved one (APA, 2000). According to DSM-IV
MDD is characterized by the occurrence of            criteria, MDD should not be diagnosed during
one or more major depressive episodes and            the first two months following a loss unless
the absence of any history of manic, mixed, or       the symptoms are not typical of normal be-
hypomanic episodes (APA, 2000). To meet cri-         reavement (e.g., worthlessness, suicidal pre-
teria for a major depressive episode, five           occupation, excessive guilt, and psychotic
symptoms must be present for at least two            symptoms). In the year following the loss,
weeks, with one of the symptoms being either         about 30% of bereaved individuals go on to
depressed mood (sad or empty) or loss of in-         develop MDD (APA, 2000).
terest or pleasure. Other symptoms include              Finally, other psychiatric disorders with de-
weight loss or gain, insomnia or hypersomnia,        pressive symptoms need to be ruled out, such
psychomotor retardation or agitation, loss of        as Bipolar Disorders, Schizoaffective Disorder,
energy, concentration problems, feelings of          and Schizophrenia. A depressive episode in
worthlessness or excessive guilt, and recur-         the context of Bipolar II Disorder is especially
rent suicidal thoughts or a suicide attempt. In      problematic because clients may not recognize
terms of suicidality, factors that increase risk     or report past hypomanic episodes (APA,
114     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

2000). In terms of differential diagnosis, bipo-    condition known as double depression (Roth &
lar depression in comparison to depression in       Fonagy, 1996). These individuals tend to have a
MDD is more likely to be severe and to have         shorter major depressive episode but relapse
psychotic or atypical features (i.e., eating and    more rapidly than those with MDD alone.
sleeping more).
Subtypes and Specifiers. DSM-IV expanded the
coding of MDD to better capture the sympto-         RECOMMENDED TREATMENTS
matic variations that have been shown to be
clinically significant as far as course and         Once the diagnostic information has been col-
treatment selection. First, MDD can be coded        lected, decisions need to be made about the
as either a single episode (first lifetime occur-   most appropriate interventions. In this sec-
rence) or recurrent (more than one episode).        tion, empirically supported treatments are re-
Episodes can be further differentiated as           viewed for the various forms of depression.
melancholic, atypical, chronic, catatonic, sea-        Both psychotherapeutic and somatic treat-
sonal, or with postpartum features. There are       ments have been extensively tested in the
also specifiers available for noting the sever-     treatment of both MDD and Dysthymic Disor-
ity of the episode, remission status, and the       der (APA, 2000; DeRubeis & Crits-Christoph,
presence of psychotic symptoms.                     1998). In fact, practice guidelines or recom-
Comorbid Disorders. Anxiety disorders, per-         mended treatments have been published by
sonality disorders, and substance dependence        APA (2000), the American Psychological As-
disorders are common comorbid conditions            sociation (DeRubeis & Crits-Christoph, 1998),
for both MDD and Dysthymic Disorder. As             and the Agency for Healthcare Policy and Re-
many as a third of those with MDD will also         search (AHCPR, 1993). These recommenda-
have a personality disorder, especially Bor-        tions are primarily based on findings from
derline Personality Disorder (Maxmen &              numerous randomized clinical trials. In the
Ward, 1995). Panic Disorder co-occurs in            future, these evidence-based guidelines may
about a quarter of the cases (APA, 2000). Com-      be adopted by managed care companies and
mon substances that are abused include alco-        other utilization review agencies as a pre-
hol, cocaine, and stimulants. It is not unusual     ferred standard of care (Persons, Thase, &
for users to gravitate toward these drugs as a      Chrits-Christoph, 1996). In this section, these
way of “medicating” an underlying depres-           recommendations are integrated to suggest
sion (Maxmen & Ward, 1995).                         treatments for the various forms of MDD and
                                                    Dysthymic Disorder.

Dysthymic Disorder
                                                    Mild to Moderate MDD
Dysthymic Disorder is characterized by the
presence of a depressed mood plus two other         MDD with mild (i.e., symptoms just meet cri-
depression symptoms that persists for at least      teria) to moderate (i.e., excess symptoms but
two years in adults (APA, 2000). Those with a       no marked impairment) symptomatology has
late onset (i.e., after age 21) have a better       been shown to respond equally well to psy-
prognosis than those with an earlier onset.         chotherapy and antidepressant medications
Like MDD, atypical features can be coded. Be-       (APA, 2000). Three major psychotherapeutic
cause of the chronic nature of their symp-          approaches have been empirically supported:
toms, individuals with Dysthymic Disorder           cognitive therapy (CT; Beck, 1976), interper-
tend to have more impaired social and emo-          sonal therapy (IPT; Weissman, Markowitz, &
tional functioning than those with MDD              Klerman, 2000), and behavior therapy (BT;
(Roth & Fonagy, 1996).                              Lewinsohn & Gotlib, 1995).
   About 80% of individuals with Dysthymic          Cognitive Therapy. Of the psychotherapies,
Disorder will eventually develop MDD, a             CT has the most extensive empirical support
                 17 • DIAGNOSIS AND TREATMENT OF ADULT DEPRESSIVE DISORDERS                     115

as an effective and specific treatment for         playing. Controlled studies have shown that
MDD (APA, 2000; AHCPR, 1993; DeRubeis &            IPT equals or nearly equals other empirically
Crits-Christoph, 1998). Basically, CT attempts     supported treatments (AHCPR, 1993; APA,
to modify negative views of the self, the envi-    2000; DeRubeis & Crits-Christoph, 1998). It
ronment, and the future through cognitive          appears that IPT is less indicated for those
techniques and behavioral exercises (Beck,         with severe interpersonal problems such as
1976). Treatment is highly structured and          Avoidant Personality Disorder (APA, 2000;
consists of about 16 to 20 sessions (see Young,    Weissman et al., 2000).
Beck, & Weinberger, 1993, for session-by-          Behavior Therapy. From a behavioral perspec-
session protocol). The first stage of therapy      tive, depression can result from too few regu-
aims at symptom reduction by challenging           lar reinforcing events (Lewinsohn & Gotlib,
negative thoughts and increasing recognition       1995). Treatment focuses on reducing the oc-
of mastery experiences. The second phase of        currence of unpleasant events and increasing
treatment targets more basic depressogenic         participation in regular pleasant activities.
assumptions such as perfectionism. Numer-          Commonly used techniques include self-
ous studies have shown that CT is at least         monitoring, contracting, activity scheduling,
equally as effective as antidepressant medica-     and skill building (e.g., assertion). This is the
tions, but may be better at preventing or de-      most systematically studied behavioral ap-
laying the occurrence of subsequent episodes       proach, but it should be noted that there are
(see Roth & Fonagy, 1996, for review). In com-     other variations (see Craighead, Craighead, &
parison to other psychotherapies, CT has           Ilardi, 1999).
been found to be equal or superior to the             Research has shown that BT is an effective
other empirically supported treatments and         treatment for MDD and compares favorably
superior to other verbal therapies (DeRubeis       to other empirically supported treatments
& Crits-Christoph, 1998; Roth & Fonagy,            (AHCPR, 1993; APA, 2000; DeRubeis & Crits-
1996). CT appears best suited for those with       Christoph, 1998). BT may be particularly indi-
mild to moderate cognitive distortions who         cated for those who show deficits in pleasant
are able to abstract and be introspective          events and who demonstrate the capacity to
(Young et al., 1993).                              comply with behavioral assignments.
Interpersonal Therapy. IPT assumes that by         Somatic Treatments. The primary somatic
dealing with interpersonal difficulties, de-       treatments that have been systematically ex-
pression can be effectively treated and pre-       amined include antidepressant medication,
vented from recurring (Weissman et al., 2000).     electroconvulsive therapy (ECT), and light
Therapy focuses on four potential problem          therapy. In terms of medication, there is very
areas: unresolved grief, interpersonal dis-        little difference in efficacy among the four
putes with others, role transitions (e.g., be-     major classes of antidepressants: tricy-
coming a parent, starting work), and               clics (TCAs), selective serotonin reuptake
interpersonal deficits (e.g., social isolation).   inhibitors (SSRIs), monoamine oxidase in-
Treatment generally entails 12 to 16 sessions      hibitors (MAOIs), and the atypical antide-
of weekly therapy (see Weissman et al., 2000,      pressants (APA, 2000). Rather, preference for
for session-by-session protocols). In the first    a particular class or drug is based largely on
phase of therapy, the clinician orients the        its more benign side-effect profile. The older
client to the interpersonal model and identi-      class TCAs and MAOIs have significant side
fies one of the four problem areas to target.      effects. As a result, APA (2000) guidelines
In the next phase, interventions are selected      generally recommend the SSRIs (e.g., Prozac,
that specifically address this area. Commonly      Paxil, and Zoloft) and the atypical antide-
used techniques include elicitation of feelings,   pressants (e.g., Wellbutrin and Effexor) as
communication analysis, use of the therapeu-       first-line antidepressants. Studies show that
tic relationship, decision making, and role        medications are comparable to empirically
116     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

supported psychotherapies, but may reduce           response or if it was found to be beneficial in
depression more rapidly (about two weeks            the past.
sooner; APA, 2000). However, side effects              Data are mixed as far as the role of psy-
may prompt dropout, and relapse is consid-          chotherapy alone with this population (Craig-
erable once the medications are discontinued        head et al., 1999; Persons et al., 1996). Roth and
(APA, 2000).                                        Fonagy’s (1996) exhaustive review of MDD lit-
Psychotherapy or Medication? APA (2000) pro-        erature concludes that the weight of evidence
vides two sets of guidelines for selecting          favors a combined approach for those with se-
treatments for mild to moderate MDD. First,         vere MDD.
psychotherapy alone is indicated when the
clinical picture includes a significant psy-
chosocial stressor, intrapsychic conflict, inter-   Subtypes of MDD
personal problems, or an Axis II disorder.          Recurrent MDD. Many of those with the re-
Other important factors to consider are pa-         current pattern will have another episode
tient preference, pregnancy, lactation, or the      within two years of remission (Roth & Fon-
wish to become pregnant. On the other hand,         agy, 1996). As a result, greater emphasis on
medication alone is recommended when there          prophylactic treatment is required for this
is a history of a prior positive response or        group. In terms of medication regimes, APA
when there is significant sleep or appetite dis-    (2000) guidelines recommend sustained use of
turbance.                                           antidepressants with tapering occurring in
    Combined treatment (i.e., psychotherapy         the month or so prior to discontinuation. In
and medication) is generally recommended            terms of psychotherapy, the recommended
for moderately severe MDD by both APA               treatment should be followed by maintenance
(2000) and AHCPR (1993). However, the data          sessions spaced biweekly and then monthly
for this recommendation are mixed at best           for approximately one year.
(Persons et al., 1996). An emerging alternative     Psychotic Features. A combination of antide-
is a sequential approach in which psychother-       pressants and antipsychotic medication is rec-
apy is offered first and medication is added        ommended for MDD with psychotic symptoms
only if there is minimal gain. Frank et al.         (APA, 2000). The primary role of psychother-
(2000) found that remission rates were better       apy has not been established, but adjunctive
for this sequential approach (79%) than for         work can be useful, especially after acute
the standard combination treatment (66%).           symptoms subside.
APA (2000) recommends that if there is not at
                                                    Melancholic Features. This is a severe form of
least moderate improvement within eight
                                                    depression that is particularly responsive to
weeks of using either medication or psy-
                                                    antidepressants (e.g., Effexor) or ECT (AHCPR,
chotherapy alone, a combination treatment
                                                    1993; APA, 2000). Psychotherapy is also recom-
should be considered.
                                                    mended, but not by itself.
                                                    Atypical Features. Symptoms such as eating
Severe MDD                                          and sleeping more are treated effectively with
Severe MDD is associated with marked func-          MAOIs and SSRIs (APA, 2000). The role of
tional impairment (e.g., inability to work or       psychotherapy has not been established for
socialize) and significant symptomotogy (e.g.,      this subtype. However, if the clinical picture
suicidal gestures). Both the APA (2000) and         includes rejection sensitivity, which is a po-
AHCPR (1993) guidelines indicate that a so-         tential atypical symptom, CT or IPT may be a
matic treatment (primarily an antidepressant)       useful adjunctive treatment component.
is the indicated intervention with or without       Postpartum Onset. MDD following childbirth
psychotherapy. ECT may be used when                 is generally treated by antidepressant
there is an urgent need for a more immediate        medication and/or psychotherapy. Because
                 17 • DIAGNOSIS AND TREATMENT OF ADULT DEPRESSIVE DISORDERS                     117

antidepressants may cause complications for       should then attempt to address both problems
those who breast-feed, clients need sound         either sequentially (with substance depend-
medical information for reaching a decision       ence targeted first) or concurrently if a dual
on how to proceed (APA, 2000). If the MDD is      diagnosis program is available.
in the mild to moderate range with no compli-     Anxiety Disorders. A number of very effective
cating features, an empirically supported         psychotherapies are available for both panic
psychotherapy alone may be indicated.             and other anxiety disorders (see DeRubeis &
Seasonal Pattern. The seasonal pattern occurs     Crits-Christoph, 1998, for review). In addi-
in about 10% of cases of MDD. Antidepres-         tion, antidepressant medications have been
sants alone or in combination with light ther-    shown to reduce symptoms of both depres-
apy is the generally recommended treatment        sion and anxiety (APA, 2000). Treatment for
regime (APA, 2000). There are no data on the      depression should follow the recommended
role of psychotherapy, but the general indica-    guidelines, but the anxiety disorder must also
tions for psychotherapy discussed above           be treated or relapse rates for both conditions
should be consulted on a case-by-case basis.      are quite high (APA, 2000).
                                                  Personality Disorders. Those who have a co-
Dysthymic Disorder                                morbid personality disorder show a less posi-
                                                  tive response to antidepressant medication
There are far fewer treatment studies on this     (APA, 2000). As a result, psychotherapy is es-
milder but more chronic depressive disorder.      pecially indicated in the overall treatment
Studies have shown that CT, IPT, and BT are       plan. CT in particular shows some advantage
effective treatment options (APA, 2000). Anti-    over other approaches in the treatment of de-
depressant medications also have been found       pression for those with a personality disorder
to be effective (APA, 2000), but as many as       (Craighead et al., 1999).
50% of dysthymics do not respond to or refuse
this option (Roth & Fonagy, 1996). Further-
more, combined treatment has been shown to        SUMMARY
be more effective than medication alone
(APA, 2000). Despite the less severe nature of    An accurate diagnosis that includes subtype
this disorder overall, outcome is not as favor-   features is critical in selecting the optimal
able as that for MDD (APA, 2000; Roth & Fon-      treatment package. For MDD in the mild to
agy, 1996). Because of the chronic nature of      moderate range, CT, IPT, and BT are consid-
this disorder, treatment may need to be more      ered empirically supported treatments. Anti-
protracted than for MDD (APA, 2000).              depressants alone or in combination with
                                                  psychotherapy are other alternatives, depend-
Comorbidity                                       ing on past response. Medications are consid-
                                                  ered more the first-line treatments for severe
Double Depression. Antidepressant medication      MDD and MDD with special features such as
has been shown to reduce symptoms of both         psychosis, melancholia, and atypical symp-
MDD and the underlying Dysthymic Disorder         toms. Treatments for Dysthymic Disorder fol-
(APA, 2000). The selection of a psychotherapy     low many of the guidelines established for
should follow the guidelines discussed above.     MDD. Comorbid conditions are common and
Combined treatment approaches are com-            treatment plans should attempt to address the
monly employed (APA, 2000).                       range of disorders that are present.
Substance Dependence. Detoxification from the        Although the recommended guidelines are
substance problem is recommended prior to         useful in making treatment decisions, they
initiating treatment for depression to assess     have several limitations. First, clients from di-
the degree to which depressive symptoms are       verse backgrounds are underrepresented in
substance-induced (APA, 2000). Treatment          clinical trials, so the generalization of findings
118      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

needs to be done cautiously. Second, although             Frank, E., Grochocinski, V.J., Spanier, C.A., Buysse,
the empirically supported treatments outper-                  D.J., Cherry, C.R., Houck, P.R., Stapf, D.M., &
form comparison treatments, a sizable pro-                    Kupfer, D.J. (2000). Interpersonal psychother-
portion of clients relapse. This suggests the                 apy and antidepressant medication: Evalua-
need for follow-up and maintenance sessions.                  tion of a sequential treat ment strategy in
                                                              women with recurrent major depression. Jour-
Finally, the highly structured nature of these
                                                              nal of Clinical Psychiatry, 61(1), 51–57.
treatments assumes that clients are ready to
                                                          Gintner, G.G. (1995). Differential diagnosis in older
take action and follow instruction. However,                  adults: Dementia, depression, and delirium.
it is not unusual for depressed clients to be                 Journal of Counseling and Development, 73(3),
ambivalent about change or to be averse to                    346 –351.
strong direction. Thus, clinicians need to be             Hamilton, M. (1960). A rating scale for depression.
sensitive to client differences and flexible in               Journal of Neurology, Neurosurgery, and Psychia-
applying these recommendations.                               try, 23, 56 –62.
                                                          Lewinsohn, P.M., & Gotlib, I.H. (1995). Behavioral
                                                              theory and treat ment for depression. In
References                                                    E.E. Becker & W.R. Leber (Eds.), Handbook of
Agency for Health Care Policy and Research                    depression (pp. 352–375). New York: Guilford
    (AHCPR) of the Depart ment of Human Ser-                  Press.
    vices. (1993). New federal guidelines seek to         Maxmen, J.S., & Ward, N.G. (1995). Essential psycho-
    help primary care providers recognize and                 pathology and its treatment (2nd ed.). New York:
    treat depression. Hospital and Community Psy-             Norton.
    chiatry, 44, 598.                                     Murray, C.J.L., & Lopez, A.D. (1996). The global bur-
American Psychiatric Association. (2000). Diagnos-            den of disease (Vol. 1). Geneva, Switzerland:
    tic and statistical manual of mental disorders (4th       World Health Organization.
    ed., text rev.). Washington, DC: Author.              Persons, J.B., Thase, M.E., & Crits-Christoph, P.
American Psychiatric Association. (2000). Practice            (1996). The role of psychotherapy in the treat-
    guideline for the treat ment of patients with             ment of depression: Review of two practice
    major depressive disorder (rev.). American Jour-          guidelines. Archives of General Psychiatry, 53,
    nal of Psychiatry, 157(4), 1– 45.                         283 –290.
Beck, A.T. (1976). Cognitive therapy and the emotional    Roth, A., & Fonagy, P. (1996). What works for whom?
    disorders. New York: International Universities           A critical review of psychotherapy. New York:
    Press.                                                    Guilford Press.
Craighead, W.E., Craighead, L.W., & Ilardi, S.S.          Weissman, M.M., Markowitz, J.C., & Klerman, G.L.
    (1999). Psychosocial treat ments for major de-            (2000). Comprehensive guide to interpersonal psy-
    pressive disorder. In P.E. Nathan & J.M. Gor-             chotherapy. New York: Basic Books.
    man (Eds.), A guide to treatments that work           Young, J.E., Beck, A.T., & Weinberger, A. (1993).
    (pp. 226 –239). New York: Oxford University               Depression. In D.H. Barlow (Ed.), Clinical
    Press.                                                    handbook of psychological disorders: A step-by-
DeRubeis, R.J., & Crits-Christoph, P. (1998). Empir-          step treatment manual (pp. 240–277). New York:
    ically supported individual and group psy-                Guilford Press.
    chological treat ments for adult mental
    disorders. Journal of Consulting and Clinical
    Psychology, 66(1), 37–52.
                 EATING
     18          DISORDERS
                 Guidelines for Assessment, Treatment,
                 and Referral


                 Cynthia R. Kalodner and Jeffrey S. Van Lone



Eating disorders are serious psychological               BULIMIA NERVOSA
disorders that affect predominately females
during adolescence and adulthood. Despite                BN is a disorder noted for binge eating, inap-
the relatively low prevalence of clinically di-          propriate compensatory behavior, and nega-
agnosed anorexia nervosa (AN) and bulimia                tive self-evaluation. Binge eating is defined
nervosa (BN), these disorders continue to re-            as eating an amount of food that is definitely
ceive a great deal of attention in the media.            larger than most people would eat under
Perhaps this is reflective of societal obsession         similar circumstances, along with a sense of
with thinness and the individuals who com-               lack of control over eating during the epi-
mit themselves to the pursuit of the thinnest            sode. There are two subtypes of BN: purging
bodies. Or perhaps it is the disbelief that              and nonpurging type. In the more common
women will vomit and exercise for hours                  purging type (Walsh & Garner, 1997), the in-
after eating. The prevalence of eating and               dividual regularly engages in self-induced
body image problems not reaching the criteria            vomiting or the misuse of laxatives, diuret-
established for AN and BN is astounding                  ics, or enemas. In the nonpurging type, the
(Kalodner & Scarano, 1992; Shisslak, Crago, &            person uses fasting or excessive exercise, but
Estes, 1995; Tylka & Subich, 1999). These eat-           does not regularly engage in self-induced
ing problems affect a tremendous number of               vomiting or the misuse of laxatives, diuret-
women and an increasing number of men and                ics, or enemas. One does not have to vomit to
include people of diverse ethnic and cultural            meet the criteria for BN. Prevalence for BN
backgrounds.                                             ranges from 1% to 3% of adolescent and
   There are two major types of eating disor-            young adult females (APA, 1994).
ders: bulimia nervosa and anorexia nervosa.
Eating disorders not otherwise specified
(EDNOS) is a term used for people with                   ANOREXIA NERVOSA
eating problems who do not fit the specific
criteria for either BN or AN. Binge eating               A key feature of AN is refusal to maintain a
disorder, under investigation as a possible ad-          minimally normal weight. People with AN
ditional formal diagnostic category, is an ex-           have an intense fear of gaining weight or be-
ample of EDNOS. A description of BN, AN,                 coming fat. It is common to deny the serious-
and additional eating problems considered                ness of low body weight. AN also falls into
EDNOS are presented. See the DSM-IV (APA,                two subtypes: restricting and binge eating/
1994) for the diagnostic criteria for these eat-         purging. Those who fall into the restricting
ing disorders.                                           type do not regularly engage in binge eating

                                                   119
120     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

or purging behavior. Those who fall into the       has been demonstrated that 50% of college
binge eating/purging type binge-eat. AN has a      women may be considered symptomatic
prevalence rate ranging from .05% to 1% of fe-     (Kalodner & Scarano, 1992). Binge eating
males in late adolescence and early adulthood      disorder is also more prevalent than AN or
(APA, 1994).                                       BN; among individuals presenting at weight
                                                   loss programs, 30% meet the criteria for the
                                                   disorder (APA, 1994). Less is known about
EATING DISORDERS NOT OTHERWISE                     the prevalence of this disorder in the general
SPECIFIED AND THE CONTINUUM OF                     population.
EATING DISTURBANCES


Eating problems exist on a continuum, with         WHO IS AT RISK?
normal eaters on one end and those with clini-
cal eating disorders on the other. The midpoint    Ninety percent of cases of AN and BN occur
intervals on the continuum may be referred to      in females (APA, 1994). Adolescence is a criti-
as subthreshold, partial syndrome, subclinical,    cal time for the development of eating prob-
or symptomatic (see Kalodner & Scarano, 1992;      lems in girls. With the onset of adolescence,
Shisslak, Crago, & Estes, 1995; Tylka & Subich,    body dissatisfaction increases; this may be a
1999).                                             result of physical changes during puberty, es-
   Serious eating problems can exist in indi-      pecially an increase in body fat. Almost 70%
viduals who do not meet the criteria of BN or      of a sample of female high school students re-
AN. In addition to understanding these eat-        ported that they were presently trying to lose
ing disorders, it is important to attend to sub-   weight (Rosen, Tacy, & Howell, 1990).
clinical presentations that are assigned to the       Though eating disorders in males are not
more heterogeneous EDNOS category. It is           common, it has been noted that eating prob-
noteworthy that NOS might be misinter-             lems in males are becoming more prevalent,
preted as connoting eating problems that are       especially among some special groups of
not serious or in need of attention. This is not   men, such as wrestlers (Enns, Drewnowski, &
at all the case, as individuals with EDNOS         Grinker, 1987) and gay men (Williamson,
can be quite distressed and in need of atten-      1999). Likewise, until recently, eating dis-
tion to the eating issues and associated psy-      orders had been described as a Western cul-
chological concerns. Binge eating disorder is      tural phenomenon facing primarily middle- to
an example of an EDNOS; it involves recur-         upper-class White females. However, eating
rent episodes of binge eating in the absence of    disorders exist among various ethnic and cul-
regular use of purging, fasting, or excessive      tural minority groups in the United States and
exercise characteristic of BN. Binges are char-    the world (see Kalodner, 1996). The assump-
acterized by some of the following: rapid eat-     tion that eating disorders do not exist in non-
ing, eating until uncomfortably full, eating       White females may lead professionals to miss
when not hungry, eating alone to avoid em-         early warning signs.
barrassment about the quantity of food con-
sumed, and feeling disgusted, depressed, or
guilty when overeating.                            COMORBIDITY
   EDNOS are much more prevalent than BN
or AN, especially among adolescent girls and       Eating disorders are often concurrent with
college women. The prevalence of partial-          other psychological issues. Depressive symp-
syndrome eating disorders is approximately         toms may be found in individuals with AN
twice that of full-syndrome eating disorders       and BN; obsessive-compulsive issues are more
(Shisslak et al., 1995). Subclinical BN is re-     often associated with AN (APA, 1994). A ge-
ported in 17% to 27% of college women              netic link between depression and eating dis-
(Kalodner & Scarano, 1992). Additionally, it       orders continues to be explored. One-third to
                                                               18 • EATING DISORDERS          121

one-half of all individuals with BN also meet      two recommended self-report measures are
the criteria for a personality disorder (APA,      the Eating Attitudes Test (EAT-26) (Garner &
1994). To be sure that associated issues are ad-   Garfinkel, 1979) and Eating Disorders Inven-
dressed in treatment, a global assessment of       tory-2 (EDI-2) (Garner, 1991). The EAT-26 is
psychological functioning is recommended as        used as a screening instrument for maladap-
a part of all clinical work with individuals       tive eating attitudes and behaviors in both ap-
who describe concerns with eating-related          plied and research settings. The EDI-2 yields
problems.                                          eleven subscales: drive for thinness, bulimia,
    Comorbidity with substance abuse is also       body dissatisfaction, ineffectiveness, perfec-
an issue. The prevalence of comorbid alcohol       tionism, interpersonal distrust, interoceptive
abuse and/or dependence in women request-          awareness, maturity fears, asceticism, impulse
ing treatment for an eating disorder ranges        regulation, and social insecurity. These sub-
from under 3% to over 59%, with a median of        scales reflect important areas of concern for
22% (Holderness, Brooks-Gunn, & Warren,            individuals with eating and body image con-
1994). Other work indicates that 34% of a          cerns. The Eating Disorder Examination (EDE,
sample of bulimic outpatients had a history of     12th ed.; Fairburn & Cooper, 1993) is a struc-
problems with alcohol or drugs, and 21% had        tured interview that operationally defines the
been in treatment for substance dependence         DSM criteria for eating disorders. For more in-
(Mitchell, Specker, & Edmonson, 1997); 33%         formation on assessment, see the excellent
of individuals with BN also meet criteria for      chapter by Crowther and Sherwood (1997).
substance abuse or dependence (APA, 1994).
It is advisable to assess for both eating disor-
ders and substance abuse in individuals seek-      SEXUAL ABUSE
ing treatment for either, as treatment issues
may be further complicated by this dual diag-      The relationship between sexual abuse and
nosis. It is a common recommendation that in-      eating disorders has received a great deal of
dividuals who have both an eating disorder         attention (cf. Fallon & Wonderlich, 1997;
and a comorbid substance use problem re-           Wooley, 1994). Determining whether sexual
ceive treatment for the substance abuse first      abuse constitutes a specific risk for eating
(Mitchell, Specker, et al., 1997). However, this   disorders or whether sexual abuse repre-
is an assumption that has not been empiri-         sents a risk for any psychiatric problem
cally tested. Mitchell et al. present a model      remains an important question (Kearney-
designed to treat patients with both substance     Cooke & Striegel-Moore, 1994). Childhood
abuse and eating disorders.                        sexual abuse is associated with increased
                                                   risk for a variety of psychiatric problems, in-
                                                   cluding eating disorders (Pope & Hudson,
ASSESSMENT                                         1992; Welch & Fairburn, 1994). Several psy-
                                                   chological factors are associated with both
Assessment of individuals with eating prob-        eating disorders and sexual abuse, such as
lems requires a comprehensive evaluation of        diminished self-esteem, self-blame, dissocia-
eating and eating-related behaviors, atti-         tion, issues with control, and personality dis-
tudes, and associated affect, as well as a         orders (Waller, Everill, & Calam, 1994). The
global assessment of psychological function-       dissociation link is a particularly interesting
ing (Crowther & Sherwood, 1997). Assess-           one (cf. Heatherton & Baumeister, 1991); it
ment may include clinical interviews, client       posits that dissociation may be a part of the
self-reports of behaviors, attitudes, and          binge eating experience as well as part of the
thoughts, self-monitoring, and behavioral ob-      repression of memories of sexual abuse. The
servation. Assessment should be considered         issue of the link between sexual abuse and
an essential part of the therapeutic experi-       eating disorders, however, remains a topic of
ence. Various self-report measures are used;       continued attention.
122     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

TREATMENT AND EFFECTIVENESS                          this rate is higher than for most other psychi-
                                                     atric problems. Death may occur due to starva-
Eating disorders are psychological problems          tion, suicide, or electrolyte imbalance (APA,
that often require collaboration between men-        1994). The physical symptoms of AN may affect
tal health professionals and physicians (espe-       most major organ systems and have serious im-
cially primary care practitioners, pediatricians,    plications for cardiovascular and renal func-
and psychiatrists). Referrals from physicians to     tioning. Starvation itself may be the cause of
mental health workers occur when medical             several medical problems, such as constipation,
professionals suspect that an eating disorder        abdominal pain, cold intolerance, lethargy, and
may be present. It is important for mental           excess energy. (For a description of the effects
health providers to refer individuals with eat-      of starvation on human functioning, see Gar-
ing disorders to physicians for an evaluation of     ner, 1997.)
physical health and nutritional status. This re-         The medical complications associated with
ferral for physical evaluation may become a          BN are related to the methods of compensation
therapeutic issue framed by the therapist as a       used to avoid the weight gain associated with
part of the recovery process. Treatment for seri-    binge eating. Metabolic complications are asso-
ous eating disorders may require hospitaliza-        ciated with vomiting and laxative and diuretic
tion, which requires mental health workers to        abuse. Vomiting is responsible for dental ero-
collaborate with other health care profession-       sion, pharyngeal/esophageal inflammation,
als. Dentists and dietitians are often essential     and esophageal and gastric tears. An addi-
to the effective identification and treatment of     tional warning about the use of syrup of ipecac
eating disorders. Because treatment of individ-      is important: When it is used repeatedly to in-
uals with eating disorders is complex, it is         duce vomiting, it may accumulate and become
highly recommended that novice therapists            harmful to the heart. Chronic laxative use may
work closely with a skilled supervisor.              lead to dependence on laxatives to stimulate
    A particular issue likely to be faced by men-    colon functioning. Diuretic use is associated
tal health counselors as well as medical profes-     with dehydration that can lead to loss of kid-
sionals working with individuals with eating         ney function. For complete information on
problems is denial of the seriousness of the         medical complications, see Mitchell, Pomeroy,
problem. Treatment refusal is a factor in the        and Adson (1997) or Sansone and Sansone
treatment of AN (see Goldner, Birmingham, &          (1994).
Smye, 1997). Psychoeducational interventions             The importance of nutritional education in
(Garner, 1997) may be less threatening than          working with individuals who exhibit any
traditional counseling, and providing accurate       eating issues cannot be overlooked. Because
information about the consequences of food re-       the impact of nutrition on eating behavior and
striction, binge eating, and methods of purg-        health is not typically part of the educational
ing, along with the effects of starvation may be     experience of the majority of mental health
a place to start with resistant clients. Self-help   professionals, referrals to registered dieti-
books (see Fairburn & Carter, 1997, for a list)      tians are necessary. To provide comprehen-
are another way to provide help to clients who       sive care, it is important for mental health
may be unwilling to commit to counseling.            providers to consult with registered dieti-
                                                     tians, thus ensuring that treatment issues rel-
                                                     evant to health and nutritional status are
MEDICAL ISSUES                                       addressed.

Eating disorders are associated with a variety
of physical health problems and medical com-         TREATMENT
plications. In AN, the medical issues that arise
are the result of starvation and malnutrition.       Treatment for eating disorders may include
AN is associated with a 10% mortality rate;          hospitalization, self-help education, family
                                                                18 • EATING DISORDERS               123

therapy, cognitive-behavioral psychotherapy,      TABLE 18.1 Organizations and Other Sources of
interpersonal psychotherapy, psychody-            Help for Individuals with Eating Disorders
namic psychotherapy, group therapy, and           American Anorexia Bulimia Association (AABA)
psychotropic medication. We briefly discuss       www.aabainc.org/home.ht ml
each of these treatment modalities and pro-       American Academy of Family Physicians (AAFP)
vide resources for additional information for     www.aafp.org/patientinfo/anorexia.ht ml
each modality presented.                          Anorexia Nervosa and Related Eating Disorders, Inc.
                                                   (ANRED)
                                                  www.anred.com
Hospitalization                                   National Association of Anorexia Nervosa and
                                                   Associated Disorders (ANAD)
Hospitalization is more often needed for indi-
                                                  www.anad.org
viduals with AN who reach a body weight
                                                  National Institute of Mental Health (NIMH)
that causes physical complications, although      www.sis.nlm.nih.gov/aids/nimh.ht ml
individuals suffering from BN who are unre-
                                                  National Eating Disorders Organization (NEDO)
sponsive to psychological treatment may also      www.kidsource.com/nedo/index.ht ml
be hospitalized. Inpatient hospitalizations       Eating Disorder Referral and Information Center
may be warranted for the following reasons:       www.edreferral.com
                                                  National Eating Disorder Information Center (NEDIC)
• To manage medical emergencies such as           www.nedic.on.ca
  severe weight loss, electrolyte imbalances,     Academy for Eating Disorders (AED)
  and hypertension.                               www.acadeatdis.org
• To prevent increased weight loss by inter-      Eating Disorders Awareness and Prevention, Inc.
  rupting patterns of bingeing, purging, and        (EDAP)
  the use of laxatives.                           www.edap.org

• To manage associated psychological compli-      Food Addicts Anonymous
                                                  www.users.erols.com/randrc/faa
  cations such as depression, family crises,
  risk of self-harm, and substance abuse dis-     HUGS International, Inc.
                                                  www.hugs.com
  orders.

   Day treatment programs provide an eco-
nomical alternative to inpatient hospitaliza-
tion, allowing clients medical monitoring,        telephone hotlines, and consultation to par-
intensive psychotherapy, and structured meal      ents and professionals. There is tremendous
programs without removing them from home.         variation on the kinds of support groups of-
Such programs may also provide a transition       fered and little evidence to indicate which
from inpatient to outpatient treatment.           kinds of groups are of most benefit to various
                                                  kinds of eating problems. Referrals to support
                                                  groups may be useful, however, as an adjunct
Self-Help                                         to counseling or as continued support after
Support or self-help groups are common in         formal therapy has ended.
the treatment of eating disorders. Support
groups usually are free of charge, held in a
                                                  Family Therapy
nontherapy setting, and often are led by per-
sons who have recovered from an eating prob-      There is more literature on family therapy for
lem rather than a mental health professional      AN than for BN, although evaluations of the
(Enright, Butterfield, & Berkowitz, 1985; Fair-   efficacy of family interventions have not been
burn & Carter, 1997). Many self-help groups       studied to the same extent as for individual
are associated with national organizations (a     and group interventions. Family therapy is a
list of Web sites is included in Table 18.1).     treatment of choice for patients under 18 years
These organizations may provide newsletters,      old who live at home. Families of individuals
124     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

with AN may have characteristics of enmesh-         validated program for treatment of BN and ad-
ment, overprotectiveness, and rigidity. En-         dresses issues specific to AN, such as the ef-
meshment and overprotectiveness refer to            fects of starvation and the need for weight
boundaries that are not well established and        gain. Specific issues that require attention in
often leave persons with AN feeling as              the treatment of AN include (Goldner & Birm-
though they cannot separate themselves from         ingham, 1994):
the family. Rigidity within the family system
involves persistence in behaviors that are not      • Medical stabilization.
adaptive. There are also issues around con-         • Establishment of therapeutic alliance.
flict, typically involving the family’s inabil-     • Weight restoration.
ity to tolerate disagreement and avoidance of       • Promotion of healthy eating attitudes, be-
topics that are likely to spark controversy. In       haviors, and activity levels.
family therapy, it is essential to treat the en-    • Psychotherapeutic treatment.
tire family as a unit, rather than allowing the     • Family and community interventions.
individual with AN to be the identified pa-
tient. Families are often in a great deal of dis-
                                                    Interpersonal Psychotherapy
tress over the low weight and food refusal of
the person with AN. Because consistent              Interpersonal therapy, originally developed
weight gain is an important part of treatment       to address depression, focuses on a detailed
for AN, this aspect of treatment must be ad-        analysis of the interpersonal context within
dressed with the entire family. Although it is      which the eating disorder developed and has
the responsibility of the person with AN to         been maintained (Fairburn, Jones, Peveler,
gain weight, parents and family are encour-         Hope, & Connor, 1993; Fairburn, 1997). Treat-
aged to assist by allowing the individual to        ment involves identifying and modifying spe-
eat foods of his or her choosing.                   cific interpersonal problems that accompany
                                                    the eating disorder. According to Fairburn,
                                                    these interpersonal problems typically fall
Cognitive-Behavioral Psychotherapy
                                                    under the following categories: grief, inter-
Cognitive-behavioral therapy is described as a      personal role disputes, role transitions, and
treatment of choice for BN (Chambless et al.,       interpersonal deficits.
1998; Wilson & Fairburn, 1993; Wilson, Fair-           The goal of interpersonal therapy is the
burn, & Agras, 1997). A primary focus is to         resolution of the individual’s interpersonal
change cognitive distortions related to body        problems. No attention is given to eating
image and other maladaptive cognitions that         habits or behavior. Although cognitive-
exist in individuals with BN (e.g., perfection-     behavioral studies have dominated the re-
ism and low self-esteem). With modifications,       search literature, controlled outcomes studies
cognitive-behavioral therapy may be success-        assessing the effectiveness of interpersonal
fully used to treat EDNOS, especially binge         therapy for BN are also impressive and are in-
eating disorder. Cognitive-behavioral therapy       cluded as an empirically supported treat-
attempts to modify behaviors by:                    ment (Chambless et al., 1998). It has been
                                                    demonstrated      that    whereas    cognitive-
• Using strategies such as self-monitoring          behavioral therapy may more rapidly achieve
  and stimulus control.                             positive outcomes, interpersonal therapy
• Educating patients about own body weight          continues to produce more positive change at
  regulation and the hazards of purging.            follow-up assessments, when cognitive-
• Presenting nutritional information.               behavioral outcomes level off (Fairburn et al.,
                                                    1993). An integration of cognitive-behavioral
   For AN, Garner, Vitousek, and Pike (1997)        and interpersonal psychotherapy may pro-
describe a cognitive-behavioral program that        vide effective intervention for long-term psy-
contains some components of the empirically         chotherapy, allowing treatment to focus on
                                                               18 • EATING DISORDERS           125

eating behaviors, faulty cognitions, and sig-      (e.g., universality, interpersonal learning, and
nificant disturbances within the individual’s      other therapeutic factors; Yalom, 1995) con-
interpersonal milieu.                              tribute to the power of group treatment.
                                                      Due to difficulties doing group work with
                                                   individuals who have AN, considerably less is
Psychodynamic Psychotherapy
                                                   known about these group interventions. Hall
Long-term psychodynamic therapy may be             (1985) noted that anorexics are often with-
useful as an alternative treatment for eating      drawn, anxious, rigid, egocentric, preoccu-
disorders when cognitive-behavioral and in-        pied with body weight and food, and have
terpersonal therapies prove ineffective. Crisp     extreme difficulty identifying and expressing
(1997) provides a well-articulated modality        feelings in group counseling. Some therapists
that integrates psychodynamic and behav-           do not use group approaches at all for the
ioral management techniques in the treat-          treatment of AN.
ment of AN. However, this therapy for eating          There is a growing body of literature on
disorders has not been scientifically vali-        the use of groups with EDNOS. McNamara
dated (Chambless et al., 1998). Additionally,      (1989) presented an example of a group inter-
there are currently no controlled studies          vention for repeat dieters. This structured
comparing long-term psychodynamic therapy          group program was designed to replace diet-
and other short-term therapies, such as cogni-     ing with healthier eating and regular, moder-
tive-behavioral therapy. Therefore, psychody-      ate exercise and to increase body esteem by
namic therapies may be implemented in              encouraging self-acceptance. Eating behav-
cases when current, empirically validated          iors and weight preoccupation were also ad-
therapies have failed.                             dressed in addition to psychological issues
                                                   common in chronic dieters, such as perfec-
                                                   tionism, assertiveness, and depression. Polivy
Group Therapy
                                                   and Herman (1992) developed a similar pro-
Counseling groups provide a promising              gram called “undieting,” aimed at reducing
modality for treatment of BN and EDNOS.            dieting behavior in overweight women. The
Groups reduce the secrecy and shame associ-        undieting program led to a significant reduc-
ated with eating problems, supply a place for      tion on various EDI subscales, indicating that
reality testing of distorted beliefs and self-     the program was able to reduce some mal-
perceptions among others who also facing           adaptive attitudes and behaviors related to
eating disorders, and provide an interper-         body and weight issues.
sonal context to facilitate links between eat-
ing disorders and interpersonal relationships
                                                   Psychotropic Medication
(Fettes & Peters, 1992; Oesterheld, McKenna,
& Gould, 1987). Approaches to group work           Medication should not be the exclusive mode
with this population vary, but most often,         of treatment for eating disorders. There is no
groups are active and symptom- and affect-         evidence that antidepressant or other medica-
focused. Common features include a focus on        tions are effective treatments for AN
the here-and-now, use of journals, cognitive       (Garfinkel & Walsh, 1997; Leach, 1995). Fur-
restructuring, incremental goal setting, and       thermore, the side effects of antidepressant
support. Interestingly, group treatment in         medications are especially problematic with
combination with additional therapy was            AN. In contrast, BN has been responsive to
found to be more effective than group ther-        treatment with antidepressant medications.
apy alone (Fettes & Peters, 1992). No particu-     Antidepressants may be useful, independent
lar type of group treatment has consistently       of the presence of depression. There is no
demonstrated better results than other types       demonstrated efficacy of a particular antide-
(Polivy & Federoff, 1997). It is likely that the   pressant over others; choice of a particular
nonspecific factors of group interventions         medication should be based on minimizing
126      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

side effects (Garfinkel & Walsh, 1997). At the            Crowther, J.H., & Sherwood, N.E. (1997). Assess-
same time, medications should be viewed as                     ment. In D.M. Garner & P.E. Garfinkel (Eds.),
part of a comprehensive treatment package                      Handbook of treatment for eating disorders (2nd
and should not be prescribed without atten-                    ed., pp. 34 –39). New York: Guilford Press.
tion to psychological issues that are addressed           Enns, M.P., Drewnowski, A., & Grinker, J.A. (1987).
                                                               Body composition, body size estimation and at-
in individual, group, or family therapy.
                                                               titudes toward eating in male college athletes.
                                                               Psychosomatic Medicine, 49, 56 –64.
                                                          Enright, A.B., Butterfield, P., & Berkowitz, B.
SUMMARY                                                        (1985). Self-help and support groups in the
                                                               management of eating disorders. In D.M.
Eating disorders represent one of the most                     Garner & P.E. Garfinkel (Eds.), Handbook of
complicated and complex of psychological                       psychotherapy for anorexia nervosa and bulimia
disorders. Although AN and BN are the most                     (pp. 491–512). New York: Guilford Press.
commonly recognizable and the most at-                    Fairburn, C.G. (1997). Interpersonal psychother-
                                                               apy for bulimia nervosa. In D.M. Garner &
tended to of eating disorders in our society,
                                                               P.E. Garfinkel (Eds.), Handbook of treatment for
the most common clinical classification is
                                                               eating disorders (2nd ed., pp. 25 –33). New York:
EDNOS. In fact, more than half of young ado-                   Guilford Press.
lescent and early adult females may be classi-            Fairburn, C.G., & Carter, J.C. (1997). Self-help and
fied as partial syndrome or symptomatic.                       guided self-help for binge eating problems. In
There are many points to consider when de-                     D.M. Garner & P.E. Garfinkel (Eds.), Handbook
veloping an integrative plan for the treatment                 of treatment for eating disorders (2nd ed.,
of an eating disorder. In working with clients                 pp. 494 – 499). New York: Guilford Press.
with eating disorders, mental health practi-              Fairburn, C.G., & Cooper, Z. (1993). The Eating
tioners should practice careful assessment,                    Disorder Examination. In C.G. Fairburn &
consider medical and comorbidity issues,                       G.T. Wilson (Eds.), Binge eating: Nature, assess-
                                                               ment and treatment (pp. 317–360). New York:
and consider referral to an expert in this
                                                               Guilford Press.
area. This chapter offered information to aid
                                                          Fairburn, C.G., Jones, R., Peveler, R.C., Hope, R.A.,
in the selection of appropriate treatment and                  & O’Connor, M. (1993). Psychotherapy and
the development of individual treatment                        bulimia nervosa: Longer-term effects of inter-
plans that integrate appropriate therapeutic                   personal psychotherapy, behavior therapy,
approaches.                                                    and cognitive behavior therapy. Archives of
                                                               General Psychiatry, 50, 419– 428.
                                                          Fallon, P., & Wonderlich, S.A. (1997). Sexual abuse
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     eating disorders. Psychiatric Annals, 25,              Handbook of treatment for eating disorders (2nd
     628–633.                                               ed., pp. 25 –33). New York: Guilford Press.
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Welch, S.L., & Fairburn, C.G. (1994). Sexual abuse           vosa. In D.M. Garner & P.E. Garfinkel (Eds.),
     and bulimia nervosa: Three integrated case              Handbook of treatment for eating disorders (2nd
     control comparisons. American Journal of Psy-           ed., pp. 67–93). New York: Guilford Press.
     chiatry, 151, 402– 407.                             Wooley, S.C. (1994). Sexual abuse and eating disor-
Williamson, I. (1999). Why are gay men a high risk           ders: The concealed debate. In P. Fallon,
     group for eating disturbance? European Eating           M. Katzman, & S. Wooley (Eds.), Feminist per-
     Disorders Review, 7, 1– 4.                              spectives on eating disorders (pp. 171–212). New
Wilson, G.T., & Fairburn, C.G. (1993). Cognitive             York: Guilford Press.
     treat ments for eating disorders. Journal of Con-   Yalom, I.D. (1995). The theory and practice of group
     sulting and Clinical Psychology, 61, 261–279.           psychotherapy (4th ed.). New York: Basic.
Wilson, G.T., Fairburn, C.G., & Agras, W.S. (1997).
     Cognitive-behavioral therapy for bulimia ner-




                    CLINICAL PRACTICE ISSUES IN
      19            ASSESSING FOR ADULT
                    SUBSTANCE USE DISORDERS


                    Boyd W. Pidcock and Joan Polansky



Substance use disorders represent the most               disorders, assessment for substance abuse and
frequently occurring mental health problem in            dependence should be a regular part of the di-
the United States (Miller & Brown, 1997;                 agnostic interview (Margolis & Zweben, 1998;
Regier et al., 1990). For example, between 1992          Miller & Brown, 1997; Perkinson, 1997). There-
and 1995, there were more than one million               fore, caution is in order when diagnosing indi-
substance abuse-related clinic admissions per            viduals who are currently abusing or
year (Margolis & Zweben, 1998). Consistently,            dependent on substances or for whom absti-
surveys show that 10% of adults develop signif-          nence is recent. The Diagnostic and Statistical
icant negative consequences resulting from the           Manual of Mental Disorders (DSM-IV-TR; Amer-
use of alcohol (Miller & Brown, 1997). Further-          ican Psychiatric Association, 2000) criteria
more, approximately 7% of Americans will de-             provide the framework for diagnosing sub-
velop drug dependence during their lifetime              stance abuse and dependence. Abuse is char-
(Brown, 1995). Given the frequency and sever-            acterized by continued substance use despite
ity of substance use disorders in mental health          the presence of significant negative conse-
settings, it is essential that clinicians develop a      quences. Because a diagnosis of abuse entails
high degree of competence in assessing and               exhibiting only one symptom within a 12-
treating substance use disorders (Margolis &             month period, the criteria for abuse are more
Zweben, 1998; Miller & Brown, 1997).                     easily met. The symptoms of abuse include: (1)
   Because drug and alcohol use often lead to            substance use being responsible for failure at
behaviors mimicking a majority of mental                 work or in the home; (2) continued use despite
19 • CLINICAL PRACTICE ISSUES IN ASSESSING FOR ADULT SUBSTANCE USE DISORDERS                   129

negative physiological consequences; (3) ongo-       Understanding the relationship between
ing use related to legal problems; and (4) sig-   coexisting disorders is essential to accurately
nificant relational problems resulting from       assessing potential client risk factors and de-
continued use. The criteria for substance de-     veloping effective treatment plans. These re-
pendence require that at least three symptoms     lationships may manifest themselves in a
be present within a 12-month period. In con-      number of ways. The presence of a mental dis-
trast to the symptoms for abuse, dependence       order may put the individual at greater risk
presents a compulsive pattern of substance        for developing substance use disorders. In
use. Dependence symptoms are (1) tolerance;       other cases, the substance use disorder pre-
(2) unsuccessful attempts to cut down or quit     cipitates or exacerbates the mental disorder.
using; (3) spending a lot of time acquiring the   Once present, the symptoms that began with
substance; (4) diminishing of relationships,      a substance disorder may continue through
work, or leisure activities because of use; and   abstinence. Sometimes the mental disorder
(5) continued use despite negative physiologi-    and substance use disorder are totally unre-
cal or psychological consequences.                lated (Nace, 1995). Overall, patients with co-
                                                  existent mental disorders are at greater risk
                                                  for relapse, and concomitantly, those who re-
DUAL DIAGNOSIS                                    lapse are more likely to develop depression. In
                                                  both cases, these individuals have an in-
In addition to developing an awareness of         creased risk for suicide (Brown, Irwin, &
substance disorders, clinicians should also       Schuckit, 1991; Galanter, Castanada, & Fer-
note that the coexistence of substance abuse      man, 1988; Kessler et al., 1994; Nace, 1995).
and mental disorders, known as dual diagno-
sis or comorbidity, is common (Miller &
Brown, 1997; Nace, 1995; Sowers & Golden,         ASSESSING SUBSTANCE USE DISORDERS
1999). Depending on the treatment specializa-
tion and setting, extant research suggests that   Given the frequency and complexity of sub-
25% to 85% of client populations that present     stance use disorders, clinicians should be
for treatment for mental health issues are also   knowledgeable in the use of a variety of reli-
experiencing the impacts of substance use         able and valid assessment tools to allow suc-
disorders (Kiesler, Simpkins, & Morton, 1991;     cessful scrutiny of their clients’ substance use.
Miller & Brown, 1997; Minkoff, 1991; Sowers       Fortunately, a number of easily administered
& Golden, 1999). Research also consistently       written and oral tools with demonstrated util-
indicates that dual diagnosis clients evidence    ity across a wide variety of research, clinical,
poorer treatment outcomes when compared           and medical contexts are available for the prac-
to clients with mental health issues alone        titioner. Although an exhaustive review of the
(Margolis & Zweben, 1999; Miller & Brown,         full range of instruments is beyond the
1997). Additionally, the dually diagnosed ex-     purview of this chapter, the assessment tools
perience higher levels of affective and anxi-     included are those of demonstrated reliability,
ety disorders, marital problems, personality      validity, simplicity, and efficacy.
disorders, psychoses, sleep disorders, sexual
dysfunctions, and posttraumatic stress dis-
                                                  The CAGE Questionnaire
orders (Margolis & Zweben, 1999; Miller &
Brown, 1997; Sowers & Golden, 1999).              Perhaps the most widely used of these tools
Clearly, clinicians who work with the dually      is also the simplest. Quick and easily admin-
diagnosed should be well trained and pre-         istered, the CAGE (Ewing, 1984, as cited in
pared to work effectively with the complex        Margolis & Zweben, 1999) includes four
manifestations that result from the inter-        questions each with key assessment dimen-
action of mental health problems and sub-         sions forming the acronym that gives the de-
stance use disorders.                             vice its name. Figure 19.1 represents the
130      PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS


1. Have you ever felt you should cut down on your         1995; Pidcock & Fischer, 1998; Pidcock, Fischer,
   drinking or drug use?                                  Forthun, & West, 2000; Sher, Wood, Crews, &
2. Have people ever annoyed you by criticizing your       Vandiver; 1995). Figure 19.2 is a reproduction
   drinking/drug use?                                     of the SMAST. Similar to the CAGE, it is easy
3. Have you ever felt guilty about your drinking?
                                                          to adapt the instrument to include substance
4. Have you ever had a drink or used drugs first thing
   in the morning (an eye opener) to steady your nerves   use (e.g., “Do you feel your alcohol and drug
   or get rid of a hangover or residual drug effect?      use is normal?” and “Have you ever attended
                                                          a meeting of Alcoholics Anonymous or Nar-
FIGURE 19.1 The CAGE Questionaire (Ewing,
                                                          cotics Anonymous?”) (Pidcock & Fischer,
1984). Source: Reprinted with permission from
Journal of the American Medical Association, vol. 252,
                                                          1998). Scores range from 0 to 13, with 3 or
pp. 1905 –1907. Copyright 1984, American Medical          above indicative of substance use problems
Association.                                              (Selzer et al., 1975). Reported internal consis-
                                                          tency reliability coefficients range from .78 to
CAGE questionnaire. Each of the four ques-                .82 (Pidcock et al., 2000), .76 to .93 (Selzer et al.,
tions assesses a domain of client information             1975), and .96 to .99 (Pokorny, Miller, & Ka-
indicative of problematic behaviors associated            plan, 1972). Validity has also been recognized
with alcohol use. The CAGE can also be
adapted to screen for the presence of problem-
atic substance use. Designed to avoid client              Please answer the following as either yes or no.
confusion and resistance, the questions are un-            1. Do you feel your alcohol and drug use is normal?
ambiguous, direct, and simple. Question 1 as-                 (By normal, we mean you drink alcohol or use drugs
sesses for clients’ awareness and reaction to                 less than or as much as most other people.)
the potential loss of control over their sub-              2. Do your parents, boyfriend, girlfriend, husband,
                                                              wife, or other near relatives ever worry or complain
stance use. Question 2 assesses the impact of
                                                              about your alcohol or drug use?
clients’ substance use on others, as well as their         3. Do you ever feel guilty about your alcohol or drug
level of denial and reaction to criticism of their            use?
substance use behaviors. Question 3 addresses              4. Do friends or relatives think you are a normal
clients’ affective reactions and responses to                 drinker/drug user?
                                                           5. Are you able to stop drinking alcohol or using drugs
their substance use. Finally, question 4 scruti-
                                                              when you want to?
nizes the potential physiological impact of                6. Have you ever attended a meeting of Alcoholics
clients’ substance use by screening for toler-                Anonymous or Narcotics Anonymous?
ance and withdrawal symptoms. Affirmative                  7. Has your alcohol or drug use ever created problems
responses to any two or more of the questions                 between you and your girlfriend, boyfriend, a par-
                                                              ent, or other near relative?
are considered indicative of client substance
                                                           8. Have you ever gotten into trouble at school or work
use problems. This short instrument has                       because of your alcohol or drug use?
demonstrated efficacy in a diverse variety of              9. Have you ever neglected your obligations, your fam-
assessment settings, such as initial client inter-            ily, school, or work for two or more days in a row
views, hospital emergency rooms, and detox                    because of your alcohol or drug use?
                                                          10. Have you ever gone to anyone for help about your
centers, where simplicity and unobtrusive
                                                              alcohol or drug use?
techniques are highly desirable (Margolis &               11. Have you ever been in a hospital or treat ment center
Zweben, 1999; Perkinson, 1997).                               because of your alcohol or drug use?
                                                          12. Have you ever been arrested for driving under the
                                                              inf luence of alcohol or drugs?
The Short Michigan Alcoholism Screening
                                                          13. Have you ever been arrested, even for a few hours,
Test (SMAST)                                                  because of other alcohol- or drug-related behaviors?

The short form of the Michigan Alcoholism
                                                          FIGURE 19.2 The SMAST-D (Pidcock & Fischer,
Screening Test (MAST, Selzer, 1971; SMAST;                1998; Selzer, Vinokur, & van Rooijen, 1975). Source:
Selzer, Vinokur, & van Rooijen, 1975) is a 13-            Reprinted with permission from Journal of Studies
item yes/no paper-and-pencil scale that has               on Alcohol, vol. 36, pp. 117–126, 1975. Copyright by
demonstrated its utility in clinical and re-              Journal of Studies on Alcohol, Inc., Rutgers Center
search contexts (Cooney, Zweben, & Fleming,               of Alcohol Studies, Piscataway, NJ 08854.
19 • CLINICAL PRACTICE ISSUES IN ASSESSING FOR ADULT SUBSTANCE USE DISORDERS                      131

as acceptably high in studies by Zung and            parents. The CAST is a 30-item inventory
Charalmpous (1975). Also of interest to clini-       with scores tabulated by all “yes” responses
cians and researchers, adapted versions have         given. Scores range from 0 to 30, with 6 or
been developed and are available for use with        above indicating the presence of negative life
males and females (SMAST-M and SMAST-F;              events associated with parental alcoholism
Crews & Sher, 1992; Sher et al., 1995) and older     ( Jones, 1985). The areas of negative life events
adults (SMAST-G; Blow, Young, Hill, Singer, &        measured by the CAST are (1) emotional dis-
Beresford, 1991, as cited in Cooney et al.,          tress associated with parental alcoholism;
1995). Overall, the SMAST is easier to adminis-      (2) perceptions related to marital discord;
ter, score, and interpret than the 25-item           (3) attempts to control parental drinking;
MAST (Selzer, 1971), and the instrument is           (4) efforts to escape from alcoholism; (5) ex-
copyright-free and open to public use (Margo-        posure to drinking-related family violence;
lis & Zweben, 1999; Perkinson, 1997).                (6) tendencies to perceive parents as alco-
                                                     holic; and (7) desire for help (Pilat & Jones,
                                                     1984, 1985). Support for the reliability of the
FAMILY HISTORY OF SUBSTANCE                          CAST is reported by Clair and Genest (1987),
USE DISORDERS                                        Dinning and Berk (1989), Roosa, Sandler,
                                                     Beals, and Short (1988), and Yeatman, Bogart,
A substantial body of research strongly sup-         Geer, and Sirridge (1994), in which they re-
ports the finding that substance use disorders       ported internal consistency reliability esti-
tend to run in families (McGue, 1999; Thombs,        mates from .88 to .94.
1999). The intergenerational linkage is transmit-        Another option for clinicians and re-
ted through both genetic and psychosocial            searchers is the CASTD (Pidcock et al., 2000).
pathways. However, the manner in which the           The instrument has been shortened to 14
susceptibility is passed through families and        items from the original version and adapted
the specific contribution of genetic versus envi-    to include the presence of parental substance
ronmental factors remains open to much debate        use (e.g., “Have you ever thought that one of
(Thombs, 1999). Because of these family-related      your parents had a drinking or drug prob-
factors, any substance use assessment should         lem?” and “Have you ever worried about a
include a careful scrutiny of the intergenera-       parent’s health because of his or her alcohol
tional family history of substance use disor-        or drug use?”). Scores of 3 or above are in-
ders. Of additional note, research has also          dicative of the presence of negative life events
demonstrated that children raised in families        associated with problematic parental sub-
with alcoholic parents are at greater risk as        stance use (Pidcock & Fischer, 1998; Pidcock
adults for anxiety, depression, antisocial traits,   et al., 2000). For the clinician, the CAST and
relationship difficulties, issues with trust, and    shorter CASTD are effective diagnostic tools
behavioral problems when compared with chil-         that measure and identify specific areas of
dren raised in households where parental alco-       client functioning impacted by the presence
holism was not a factor (Brown & Schmid,             of parental substance use disorders. Both in-
1999). Importantly, the family history assess-       struments are copyright-protected (CAST;
ment can provide the clinician with a full range     Jones, 1981, 1982); permission for use should
of information relevant to mental disorders that     be obtained from the author prior to use.
goes well beyond risk factors for substance use
disorders (Margolis & Zweben, 1999).
                                                     TREATMENT PLANNING

The Children of Alcoholics Screening
                                                     Because a large proportion of clients with sub-
Test (CAST)
                                                     stance use problems also have additional coex-
The CAST ( Jones, 1981/82) identifies latency-       isting disorders, therapists often need to
age children, adolescents, and adults who            coordinate care with other helping profession-
are living with or have lived with alcoholic         als. Obtaining client consent in the form of
132     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

signed written releases provides the founda-        and ease of implementation across diverse
tion for contacting treatment programs and          treatment models and staffs representing
physicians prescribing medications. Contact-        multiple levels of education and training
ing the appropriate resources is an essential       (Brady et al., 1996).
step in the assessment and treatment planning           Prochaska et al. (1992) define each of the
process because it provides collateral data         five stages as a series of predictable experi-
about the client and an ability to engage in hy-    ences and tasks that need to be accomplished
pothesis testing with other professionals.          prior to progressing to the next stage. As with
   As with any treatment planning, clearly          most developmental models, the stages of
defining the problem is paramount. However,         change overlap in some areas and maintain
with substance use disorders, problem identi-       discrete categories in others. The model postu-
fication is often further complicated by the        lates a potential to become stuck in one or
presence of client denial and the dynamic na-       more stages. Additionally, the model inte-
ture manifest in dual diagnosis. With dually        grates a systems-based spiral pattern account-
diagnosed individuals, the early focus of treat-    ing for relapse as an integral part of the change
ment should be on substance use issues, but         process.
other mental health concerns also should be             With the key features of the model in
addressed. Despite the movement advocating          mind, a closer examination of the stages is in
for controlled use (Sobell & Sobell, 1978, 1993),   order. The first stage, precontemplation, is char-
the majority of research consistently supports      acterized by the absence of motivation to
abstinence as a primary treatment goal              change because the individual does not be-
(Brown, 1995; Goldsmith, 1997; Schuckit, 1994;      lieve he or she has a problem. Precontempla-
Wallace, 1989, 1996). The most effective treat-     tive clients are helped to become aware of
ment strategies prioritize and integrate both       their emotional response to the negative con-
substance use and mental health treatment           sequences associated with the behaviors in
goals and objectives (Brown, 1995; Margolis &       question. Consciousness-raising interven-
Zweben, 1998; Miller & Brown, 1997; Nace,           tions will help the client move to the contem-
1995). Additional research demonstrates that        plative stage (Prochaska & Norcross, 1999).
optimal treatment planning successfully ad-         Contemplative clients understand they have a
dresses dual diagnosis and the individual’s         problem and begin evaluating their options.
readiness for change (Prochaska, DiClemente,        Often, individuals in the contemplative stage
& Norcross, 1992). Accordingly, treatment is        are far from committing to actual change.
appropriately matched with the client’s disor-      Prochaska, DiClemente, and Norcross (1994)
der (Margolis & Zweben, 1999; Miller &              propose that an awareness of the problem and
Brown, 1997).                                       solution is necessary before a successful com-
                                                    mitment to the process of change can occur.
                                                    Therapists should engage clients in activities
Processes of Change
                                                    enhancing both the cognitive and emotional
Prochaska et al.’s (1992) transtheoretical          awareness of the problem.
model for assessing the processes of change             The third stage, preparation, involves both
provides treatment recommendations for in-          client intentions and behaviors. Individuals
dividuals at each stage. The overall model can      in the preparation stage should be encouraged
be used to help facilitate the clinician’s un-      to continue small changes while carefully
derstanding that clients can simultaneously         planning detailed schemes for action. Thera-
be at different stages of change in relation to     pists need to provide support and encourage-
their co-occurring substance and mental dis-        ment for clients in the preparation phase so
orders and, thus, improve treatment planning        that they can develop a sense of self-efficacy
efficacy (Brady et al., 1996; Miller, 1995). Per-   (i.e., they believe that through their own ac-
haps the most salient features of the transthe-     tions they can change their lives in key ways)
oretical model are realized in its simplicity       (Prochaska & Norcross, 1999). The action stage
19 • CLINICAL PRACTICE ISSUES IN ASSESSING FOR ADULT SUBSTANCE USE DISORDERS                             133

is the initiation of plans made during the           • Clinicians should routinely assess for sub-
preparation stage. The plans should modify             stance use disorders and the possibility of
the behaviors, experiences, and environments           dual diagnosis.
of the individual engaged in the change pro-         • Substance use disorders result from a com-
cess. Maladaptive behaviors are not simply             plex interaction among biopsychosocial
extinguished but countered with healthier,             factors unique to each client.
proactive behaviors mediated by such means           • Substance abuse is a maladaptive pattern
as counterconditioning, stimulus control, and          of substance use leading to significant neg-
contingency management. During this stage,             ative consequences.
therapists should assist clients in evaluating       • Substance dependency is a generalized
their change process in order to continue and          loss of control of the substance leading to
reinforce the momentum generated by imple-             negative consequences in key areas of
menting changes.                                       functioning.
   The first few months of the maintenance stage     • Clinicians should routinely use reliable
are the most likely time for relapse and for old       and valid assessment tools when screening
behaviors to reoccur (Prochaska et al., 1994).         for substance use disorders.
Therefore, much of the work to be accom-             • With substance use disorders, clearly defin-
plished during this stage is the continued re-         ing the problem is essential for effective
placement of old behaviors, experiences, and           treatment planning.
environments with a healthier lifestyle. Given       • Clinicians should utilize the processes of
the increased risk of relapse during this stage,       change for treatment planning and delivery.
consolidation of gains and continued vigilance       • Effective relapse prevention strategies are
to the possibility of relapse is in order. Clini-      a vital component of effective treatment of
cians need to be especially supportive of client       substance use disorders and working with
gains, as well as continuing to monitor for            dual-diagnosed clients.
signs of relapse-related behaviors.
   Relapse prevention interventions grew from
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                   MANAGEMENT OF
      20           PERSONALITY DISORDERS


                   Darcy Haag Granello and Paul F. Granello



The Diagnostic and Statistical Manual, fourth           perceiving, relating to, and thinking about the
edition, text revised (DSM-IV-TR), of the Amer-         environment and oneself that are exhibited in
ican Psychiatric Association (APA) defines              a wide range of social and personal contexts”
personality disorders as “enduring patterns of          (APA, 2000, p. 685). These patterns have an
136     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

onset of no later than early adulthood and        There is also a lack of clinical focus, with
are inflexible and maladaptive, resulting in      treatment typically focusing on Axis I disor-
significant impairment in social or occupa-       ders, and comorbid Axis II disorders remain-
tional functioning. The personality disorders     ing undiagnosed. In addition, people with
are coded on Axis II, and the DSM-IV in-          personality disorders seldom seek treatment
cludes 10 specific diagnoses, grouped into        for their personality disorder, given the ego-
three clusters: Cluster A, the odd-eccentric      syntonic nature of the disorders. Only about
cluster (paranoid, schizoid, schizotypal);        one-fifth of people with an Axis II diagnosis
Cluster B, the dramatic-emotional cluster         receive treatment for the disorder, and most
(antisocial, borderline, histrionic, narcissis-   who enter treatment do so because of coexist-
tic); and Cluster C, the anxious-fearful          ing Axis I disorders. Thus, estimates of preva-
cluster (avoidant, dependent, obsessive-          lence are imprecise, and range from 10% to
compulsive). There is also a classification for   13% in community samples (Crits-Christoph,
Personality Disorder, Not Otherwise Speci-        1998) to up to 60% in clinical samples (Kaplan
fied (NOS), that is not included in any spe-      & Sadock, 1998).
cific cluster. The NOS diagnosis is intended         People with personality disorders are noto-
for persons who meet the general criteria for     riously difficult to treat, and most of the litera-
a personality disorder but whose symptoms         ture focuses on helping people to manage their
do not meet the criteria for any specific dis-    disorders or controlling the behaviors or symp-
order. Additionally, maladaptive personality      toms associated with their disorders. Clients
traits that do not meet the threshold for a       with personality disorders often terminate
personality disorder can be coded on Axis II,     treatment prematurely (Seligman, 1998). In
with the proper notation that differentiates      one study with persons with Paranoid Person-
traits from the full-blown disorder; for exam-    ality Disorder, more than 90% of the partici-
ple, the clinician would record: Axis II:         pants dropped out before the completion of
V71.09, no diagnosis, with borderline person-     treatment (Mavissakalian & Hamann, 1987).
ality traits.                                        Treatment with clients with personality
   With the exception of Avoidant Personal-       disorders is often long term, with clients en-
ity Disorder, the personality disorders tend      tering and leaving therapy many times dur-
to be ego-syntonic. That is, persons with these   ing their lives. Comorbidity with Axis I
disorders typically do not perceive their ac-     disorders is very high. For example, between
tions to be problematic, blaming the actions      36% and 76% of clients with anxiety disor-
of those around them for their distress. This     ders and 36% to 65% of clients with mood
differs significantly from most of the major      disorders also have a coexisting personality
Axis I disorders, which are typically ego-        disorder (Ruegg & Frances, 1995). In other
dystonic, or troubling to the person with the     studies, 39% of clients with bulimia had a
diagnosis. Thus, persons with personality         comorbid personality disorder (Fahy, Eisler,
disorders often make poor historians, and it      & Russell, 1993), and 20% of clients with
may be necessary to solicit supplementary         Obsessive-Compulsive Disorder also fit the
information from other sources when mak-          criteria for Borderline Personality Disorder
ing a diagnosis.                                  (Hermesh, Shahar, & Munitz, 1987).
                                                     These comorbidity rates underscore the
                                                  importance of accurate diagnosis of a coex-
PREVALENCE AND COMORBIDITY ISSUES                 isting personality disorder when treating
                                                  Axis I disorders. The presence of a personal-
Personality disorders have high rates of          ity disorder can significantly impact the
prevalence, although accurate rates are diffi-    treatment of other disorders, but because
cult to measure. One problem is with assess-      they are often not the focus of treatment,
ment, as there are no instruments available to    they can go undetected. Many studies have
accurately diagnose a personality disorder.       found that the presence of a personality
                                        20 • MANAGEMENT OF PERSONALITY DISORDERS                  137

disorder can severely limit the treatment ef-        OVERALL TREATMENT CONSIDERATIONS
fectiveness of Axis I disorders (e.g.,
Granello, Granello, & Lee, 1999).                    Despite the high prevalence of personality
   Additionally, the high rates of comorbid-         disorders in both the clinical and general
ity among Axis I and Axis II disorders can           population, there is a lack of empirical re-
significantly affect the ability of clients to       search on treatment. The vast majority of
manage their personality disorders. For ex-          writing is in the form of theoretical analysis
ample, substance abuse is very high among            or case report. Thus, from a research perspec-
clients with Axis II disorders, often as an at-      tive, very little can be said about the manage-
tempt to self-medicate. Thus, management of          ment of the individual personality disorders.
the personality disorder often cannot begin             In general, a multifaceted approach that
until the substance abuse issues are under           emphasizes cognitive and behavioral interven-
control. Using data from the Epidemiological         tions is the strategy emerging in the literature.
Catchment Area Program, Swartz, Blazer,              Cognitive interventions, focusing on identify-
George, and Winfield (1990) found that for           ing and challenging irrational thoughts, are
people with the diagnosis of Borderline Per-         gradually shifted from the thoughts that trig-
sonality Disorder, many had coexisting Axis          ger the presenting symptoms to the core
I disorders that interfered with their ability       thoughts that underlie the dysfunction of the
to manage their personality disorder. These          personality disorder (Beck & Freeman,
included Generalized Anxiety Disorder                1990). Behavioral therapy has been reported to
(56%), Major Depression (41%), Agoraphobia           enhance treatment success, particularly to
(37%), Social Phobia (35%), Posttraumatic            modify extremely dysfunctional and self-
Stress Disorder (34%), and alcohol/substance         destructive behavioral patterns (Seligman,
abuse (22%).                                         1998). These approaches appear to be more ef-
   A final difficulty with comorbidity is the        fective in the overall management of the dis-
high rates of coexisting disorders within the        order than the psychodynamic approach, al-
personality disorders themselves. Although           though this preference has not been validated
the diagnostic categories appear discreet in the     by research. There is some concern that a psy-
DSM-IV-TR (APA, 2000), in reality, many              chodynamic approach may be ineffective,
clients have overlapping symptoms and meet           given the lack of insight evidenced by most
the criteria for several personality disorders si-   people with personality disorders (Armstrong,
multaneously. For example, between 30% and           Cox, Short, & Allman, 1991). Psychoeduca-
56% of clients with Paranoid Personality Disor-      tional groups that emphasize life skills train-
der also meet the criteria for Narcissistic Per-     ing may be appropriate, with a focus on social
sonality Disorder, and up to 50% of clients          skills, life management (e.g., personal care,
with Avoidant Personality Disorder also meet         time management, cooking, nutrition), prob-
the criteria for Schizotypal Personality Disor-      lem-solving training, and self-control skills
der (Zimmerman & Coryell, 1990). It is uncer-        (e.g., emotion regulation, distress tolerance).
tain whether Axis II overlaps such as these          In-patient or day treatment programs may be
represent true comorbidity or whether they           necessary during acute exacerbations (Piper,
occur because of deficiencies in the current         Joyce, Azim, & Rosie, 1994).
conceptualizations of personality disorders or          Clinicians may want to use adjuncts to in-
because of limitations in currently available        dividual therapy, including family and cou-
measures of assessment (Alden, 1989). Regard-        ples counseling. The behaviors exhibited by
less of the cause, the overlap between the per-      the client with a personality disorder are
sonality disorders makes controlled studies of       often maintained in relationships that allow
individual personality disorders extremely dif-      the dysfunction to continue. Therefore, these
ficult to conduct and makes the findings of          same relationships must be altered to allow
such research difficult to apply to clients with     the dysfunction to diminish (Benjamin, 1993).
multiple Axis II diagnoses.                          Additionally, the use of self-help groups (e.g.,
138     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

Alcoholic Anonymous) may be useful for             & Siever, 1995). Individuals with this disorder
clients struggling with substance abuse in ad-     use fantasy as a defense and have extreme
dition to their personality disorder. Finally,     difficulty establishing and maintaining rela-
because of disruptions in occupational func-       tionships. Thus, these clients need a quiet, re-
tioning, career counseling may be an impor-        assuring clinician who can maintain interest
tant adjunct to therapy.                           in them without requiring a reciprocal re-
                                                   sponse. Although they can join group counsel-
                                                   ing with more success than clients with
SPECIFIC TREATMENT RECOMMENDATIONS                 Paranoid Personality Disorder, they must be
BY DISORDER                                        protected from aggressive group members
                                                   who challenge their silence (Kaplan & Sadock,
Paranoid Personality Disorder                      1998).

There are no controlled studies for treatment
of Paranoid Personality Disorder, but case re-     Schizotypal Personality Disorder
ports and nonrandomized studies have               A combination of social skills training, includ-
shown support for several interventions. A         ing attention to interpersonal boundaries, and
behavioral deficit and skills training ap-         educative therapy, including reality testing,
proach that teaches clients to monitor their       has been advocated in the literature on this
behavioral deficits (e.g., infrequent eye con-     disorder (Stone, 1985), although no controlled
tact, flat affect) and specific skills to over-    studies exist. Anecdotal reports suggest that
come these deficits has met with some              these clients tend to decompensate in unstruc-
success, as have cognitive interventions.          tured psychotherapy, and it should be noted
However, it should be noted that clients with      that as many as 25% of people with Schizotypal
Paranoid Personality Disorder have ex-             Personality Disorder develop schizophrenia.
tremely high dropout rates, and treatment          There have been some reports that clients with
gains for those who remain come very slowly.       moderately severe symptoms can benefit from
Challenging the underlying defenses may            the use of neuroleptics, although problems may
lead to a loss of self-esteem, and clinicians      arise with medication compliance. Case man-
must take care not to engage in the client’s ar-   agement issues are particularly important, as
gumentative or threatening style. Because          many struggle to maintain housing, food, and
trust and intimacy are core concerns to these      employment.
clients, clinicians should be honest and
straightforward in all interactions and limit
their interpretations of client behaviors,         Antisocial Personality Disorder
which may prove to be too threatening. A pro-      These clients are typically involuntary and
fessional stance, rather than an overly warm       therefore have limited motivation for treat-
one, will benefit the therapeutic relationship.    ment. Because of their ability to manipulate
                                                   others, it is essential that clinicians develop
                                                   and maintain firm limits and frequently ana-
Schizoid Personality Disorder
                                                   lyze the client’s actions and statements for
Individuals with Schizoid Personality Disor-       the possibility that they are part of the manip-
der are rarely motivated to enter treatment.       ulation of the therapist. Although there are
When they do, therapy should be aimed at           no randomized, controlled studies, there are
achieving modest reductions in social isolation    many uncontrolled studies and narrative
and in promoting more effective adjustment to      reports. This emphasis in the literature under-
new circumstances. Anecdotal reports suggest       lies the importance of finding effective treat-
some success with cognitive interventions and      ment interventions for these clients and
social skills interventions (Kalus, Bernsteing,    reveals the intractability of the disorder. There
                                      20 • MANAGEMENT OF PERSONALITY DISORDERS                 139

seems to be no intervention that yields consis-    important components of treatment are help-
tently positive results. Suggested interventions   ing clients define the onset of the repression
include reality therapy to promote an under-       and clarifying the reality of their relation-
standing of consequences of behavior, be-          ships with others, rather than allowing
havioral therapy to promote problem-solving        clients’ feelings to define that reality (An-
and decision-making skills, and cognitive ther-    drews, 1984). Clinicians are cautioned to mon-
apy to promote moral development, abstract         itor the erotic transference that is common
thinking, and modification of dysfunctional        with histrionic clients (Seligman, 1998). Cog-
thoughts (Seligman, 1998). Medication, primar-     nitive therapy may be effective, but reliance on
ily to address anger and underlying mood dis-      cognitions and logic is likely to be a very new
orders, is sometimes recommended (Sperry,          experience for these individuals (Beck & Free-
1995), but must be used with caution, given the    man, 1990). Helping clients search for and de-
propensity of these individuals toward sub-        fine reality and blocking attempts to “play
stance abuse.                                      games” with the clinician can help build
                                                   transferable skills and aid in problem solving
                                                   and decision making. To prevent premature
Borderline Personality Disorder
                                                   termination, cognitive therapy should be at-
There are few empirical studies but many an-       tempted only after a strong therapeutic al-
ecdotal reports of attempts to manage this         liance has been formed, and challenges to
disorder. All authors emphasize the impor-         irrational thoughts must never be perceived as
tance of boundaries and the use of the thera-      an attack. Finally, some clients may benefit
peutic relationship to provide a corrective        from medications to ease the symptoms of
emotional experience. Linehan’s Dialectical        mood disorders that often accompany this dis-
Behavioral Therapy (DBT) (1993) has been           order. However, the distribution of the med-
promoted for the treatment of clients with se-     ication must be tightly monitored, as clients
vere Borderline Personality Disorder; it in-       with Histrionic Personality Disorder are prone
cludes goal setting to increase safety and         to substance abuse and suicidal gestures.
stability and emotional containment. Others
advocate a combination of affect facilitation
                                                   Narcissistic Personality Disorder
(learning that emotional expression does not
necessarily lead to harm), holding without         With no controlled studies and very little re-
overcontaining (setting firm boundaries and        search or field-based accounts available, lim-
structure only about important issues), safety     ited inferences can be made about treatment of
contracts, and an up-front understanding of        this disorder. Some anecdotal reports have in-
time-limited treatment (Miller, 1995). Cogni-      dicated that a psychodynamic approach may
tive therapy also has been promoted, but must      be more warranted with these clients than
be done within the context of an extremely         with the other personality disorders. However,
supportive relationship. Hospitalizations for      this insight-oriented approach would be war-
periods of acute exacerbations may be neces-       ranted only for those with a mild dysfunction
sary to keep these clients alive.                  who have some motivation to engage in ther-
                                                   apy (Seligman, 1998). One approach includes
                                                   gentle cognitive reorientation to establish a
Histrionic Personality Disorder
                                                   baseline of rapport between the client and cli-
Uncontrolled studies and reports from the field    nician; then a more direct approach can be
underscore the importance of addressing the        gradually integrated. The goal is to probe and
underlying defenses of denial and repression.      modify self attitudes and social habits. Millon
Feelings identification and clarification is im-   (1996) suggested group or family therapy to
portant to the therapeutic process (Kaplan &       provide feedback to the client, but cautions
Sadock, 1998) for those with this disorder. Two    that intensive feedback can be very wounding
140     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

to their highly defended egos and must be in-         others accept and reinforce the changes the
tegrated slowly.                                      client is making. These clients respond well to
                                                      therapy that is directive and active, but the cli-
                                                      nician must take care not to become the object
Avoidant Personality Disorder
                                                      of the client’s attachment.
There is a strong overlap in the DSM-IV-TR
(APA, 2000) criteria between Avoidant Person-
                                                      Obsessive-Compulsive Personality Disorder
ality Disorder and Social Phobia, and many of
the same interventions are used. Behavioral           No outcome studies on this disorder have been
therapy, common to treatment of all the pho-          conducted, and reports from the field suggest
bias, is a cornerstone of treatment for clients       that treatment of these clients is long and
with Avoidant Personality Disorder. However,          complex, with many clinicians experiencing
because of their fragility, behavior therapy          strong countertransference. Cognitive thera-
must not be attempted until there is a strong         pies have met with some success, and clients
and trusting therapeutic alliance (Kaplan &           with Obsessive-Compulsive Personality Dis-
Sadock, 1998). Behavioral tasks that encourage        order tend to respond well to interventions
social contact must be taken in very small in-        that are cognitive, nonemotional, structured,
crements, as failure can reinforce feelings of        problem-focused, and present-oriented (Beck
humiliation and low self-esteem. Group ther-          & Freeman, 1990). Others have recommended a
apy may be useful to help clients understand          combination of cognitive therapy (e.g., self-
their interpersonal sensitivity, and assertive-       monitoring, thought stopping) with behavioral
ness training has received some attention as          interventions (e.g., guided imagery, relaxation,
an important adjunct to therapy. Cognitive            self-practice) (Sperry, 1995). Group therapy
therapy has been supported anecdotally,               also may be used as an adjunct, but clinicians
with therapeutic interventions reinforcing the        may find that they have to keep these clients
idea that the catastrophizing thoughts of the         from monopolizing the group.
client seldom come to fruition in real-world
contacts.
                                                      SUMMARY

Dependent Personality Disorder
                                                      Although personality disorders remain very
Although the diagnosis of all personality disor-      difficult to treat, there is evidence that thera-
ders must be made in culturally appropriate           peutic interventions can help clients manage
ways, this is particularly true of the diagnosis of   many of the symptoms of these disorders. Re-
Dependent Personality Disorder, where care            search is extremely limited, but generally
must be taken not to diagnose a woman who is          suggests a cognitive-behavioral approach that
acting in a culturally appropriate sex role.          focuses on symptom management rather than
Treatment of the disorder depends on a strong         insight-oriented therapy. Common therapy
therapeutic relationship in which the clinician       adjuncts include psychoeducational groups,
can gradually encourage independence and              life skills groups, problem-solving training,
self-assertion within the counseling relation-        and family therapy. Clinicians working with
ship. Small steps toward establishing more in-        these clients are cautioned to make thorough
dependence can be reinforced with relaxation          diagnositic assessments to check for comorbid
techniques to help lessen the anxiety that            Axis I and Axis II disorders that can signifi-
comes with decision making. More than with            cantly affect treatment. Finally, clinicians are
other disorders, the person with Dependent            reminded that therapy with these clients can
Personality Disorder relies on relationships that     be a long-term endeavor, with clients entering
support and maintain the dysfunctional behav-         treatment during acute exacerbations of the
ior. Therefore, family and couples counsel-           disorder and leaving when these symptoms
ing is particularly important to help significant     are in remission.
                                            20 • MANAGEMENT OF PERSONALITY DISORDERS                          141

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                 SCHIZOPHRENIA AND
     21          SEVERE MENTAL ILLNESS
                 Guidelines for Assessment, Treatment,
                 and Referral


                 Susan Bichsel



The focus of this chapter is on the severe men-          antipsychotic medication is effective in reduc-
tal illnesses, more recently referred to as neu-         ing psychotic symptoms in 60% of patients and
robiological disorders. The term severe mental           in 70% to 85% of those experiencing symptoms
illness was defined in 1993 by the National              for the first time (National Mental Health Ad-
Mental Health Advisory Council, an arm of                visory Council, 1993). The “second-generation”
the National Institute of Mental Health, as in-          antipsychotics, such as clozapine, risperidone,
cluding “disorders with psychotic symptoms               and olanzapine, are effective for an additional
such as schizophrenia, schizoaffective disor-            33% of individuals with psychosis who do not
der, manic depressive disorder, autism, as well          respond to the traditional antipsychotics. In
as severe forms of other disorders such as               the treatment of Bipolar Disorder, approxi-
major depression, panic disorder, and obses-             mately 75% of individuals respond to lithium,
sive compulsive disorder” (National Mental               carbemazepine, or a combination of several
Health Advisory Council, 1993). The National             medications. For severe depression, at least
Mental Health Advisory Council has deter-                80% of individuals respond to tricyclics (Elavil,
mined that in any one-year period, 2.8% of the           Norpramine), selective serotonin reuptake in-
adult population in the United States is af-             hibitors (SSRIs) such as Prozac and Zoloft, or
fected by severe mental illness. This means              monoamine oxidase inhibitors (MAOIs) such
that in any given year in the United States, ap-         as Nardil and Parnate. For severe Panic Disor-
proximately 5.5 million individuals are diag-            der, between 70% and 90% of individuals re-
nosed with a neurobiological disorder.                   spond to an antidepressant or benzodiazapine
                                                         class of medication. Of all the severe mental ill-
                                                         nesses, only autism has no effective medication
ARE MENTAL ILLNESSES TREATABLE?                          options at this time (Torrey, 1997).
                                                            In addition to pharmacological treatment,
It is a persistent myth that there are no effec-         many individuals benefit from rehabilitative
tive forms of treatment for individuals with             and supportive counseling (Carter, 1998; Fen-
severe mental illness. However, according to             ton & McGlashon, 1997; Hellkamp, 1993;
the 1993 report of the National Mental Health            Kates & Rockland, 1994; Kopelowicz & Liber-
Advisory Council, the efficacy of many treat-            man, 1998; Mueser & Gingerich, 1994; Mueser
ments for severe mental disorders is compara-            & Glynn, 1993). In fact, contrary to the pre-
ble to that of other branches of medicine,               vailing myths surrounding severe mental ill-
including surgery. For example, in the treat-            ness, there are effective treatments for the
ment of schizophrenia and Schizoaffective                majority of individuals who are diagnosed
Disorder, research has shown that traditional            with these disorders. In many instances,

                                                   142
                                 21 • SCHIZOPHRENIA AND SEVERE MENTAL ILLNESS                 143

multiple interventions are most effective         treat ment and medication rejection by pa-
when done conjointly, although the timing of      tients, individuals with mental illness who
various interventions should be adjusted in       are not following prescribed treat ment
accordance with individual need (Fenton &         regimens are more likely to be at risk for
McGlashon, 1997; Kates & Rockland, 1994).         self-neglect, combativeness, and/or aggres-
Most forms of mental illness require a careful    siveness (Torrey, 1997). Studies have shown
coordination of drug therapy accompanied by       that the vast majority of individuals with
social work, nursing, case management, fam-       schizophrenia are not violent towards oth-
ily education, and counseling interventions.      ers; a small number of them, however, when
Most promising, in a 30-year longitudinal         left untreated, are.
study, Harding, Zubin, and Strauss (1992) re-
ported that 66% of individuals treated for se-
vere mental illness were capable of achieving     THE SOCIAL COSTS OF SEVERE
considerable improvement and recovery.            MENTAL ILLNESS
These individuals were eventually capable of
integrating successfully into the community       Schizophrenia is one of the most common and
with jobs, families, friends, and homes.          serious of the mental illnesses. In the United
   Nonetheless, according to the National         States alone, there are approximately 2.5 mil-
Mental Health Advisory Council, only 60% of       lion people diagnosed with the disease
adults diagnosed with severe mental illness       (Mueser & Gingerich, 1994, NARSAD, 1987;
receive treatment in any given year. For          Regier, Farmer, Lock, Keith, & Rae, 1993).
schizophrenia, the treatment rate is even         While the diagnosis of schizophrenia is com-
lower, with only 50% of affected individuals      plicated by a wide variance in symptomatol-
receiving necessary treatment (Von Korff          ogy, individual difference, and outcome,
et al., 1985). One of the most serious problems   epidemiological research consistently reports
in the treatment of schizophrenia is the re-      its incidence in the general population at be-
fusal to take prescribed medications, largely     tween 0.5% to 2.5%, regardless of culture,
because of their unpleasant side effects. Al-     gender, or time in history (APA, 1994). Ap-
though only a few patients refuse medica-         proximately 20% of all individuals with
tions entirely, nearly 50% stop taking them in    chronic disability (including physical and
the first year and nearly 75% in the first two    mental illnesses) are diagnosed with schizo-
years (Harvard Medical School, 1992). These       phrenia (Mueser & Gingerich, 1994). In this
data are of particular concern, as research       country alone, more than 1 million people
shows that an individual’s acceptance or re-      with schizophrenia account for 75% of all
jection of prescribed medications is the single   mental health expenditures (Harvard Med-
greatest determinant of effective treatment       ical School, 1995). These numbers do not in-
(Fenton, Blyler, & Heinssen, 1997). Patients      clude the additional 1.1 million individuals in
who do not take antipsychotic medications         the United States diagnosed with Bipolar Dis-
will probably receive little benefit from any     order, and the even larger number with severe
other kind of treatment.                          depression or Obsessive-Compulsive Disorder
   Torrey (1995) argues that low treat ment       (Torrey, 1995).
rates are a direct effect of changes in state         The annual cost of treating severe mental
laws that made involuntary hospitaliza-           illness for patients, family members, and the
tion and treat ment more difficult to utilize     community is extraordinary. In the United
for individuals with little insight into their    States, the cost each year is believed to exceed
illnesses. Indeed, debate persists among          $48 billion for schizophrenia alone (NARSAD,
civil rights lawyers, patient advocates, fam-     1987). This total includes the costs of medical
ily members, and providers about an indi-         treatment, social security payments, and wages
vidual’s “right” to be psychotic (Torrey,         lost because of illness for every person diag-
1997; Woolis, 1992). Whatever the cause of        nosed with the disease. The shift from treating
144     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

people with mental illness in institutions to       THE DIAGNOSIS OF SCHIZOPHRENIA
treating them in outpatient mental health cen-
ters, although fiscally appealing, has further      The schizophrenia spectrum disorders are
complicated the treatment of this complex ill-      a group of psychiatric disorders that are
ness (Rose, 1979). As a result of deinstitution-    thought to be similar in onset, symptoms, lev-
alization, illnesses such as schizophrenia have     els of impairment, and response to treatment
been thrust into the political and social           (Mueser & Gingerich, 1994). These disorders
spheres with related issues such as housing         include Schizophrenia, Schizophreniform
discrimination, homelessness, poor medical          Disorder, Schizoaffective Disorder, and
access and care, patient civil rights, poverty,     Schizotypal Personality Disorder. The schizo-
and social stigma compounding what is al-           phrenias are broken down by the Diagnostic
ready a devastating experience for people who       and Statistical Manual of the American Psychi-
are ill.                                            atric Association (DSM-IV) into four distinct
    Studies show that after several psychotic       types: paranoid, undifferentiated, disorgan-
episodes, many individuals diagnosed with           ized, and catatonic. The four subtypes of
schizophrenia are found on the street, in a         schizophrenia are thought to vary somewhat
public shelter, or in jail (Koegel, Burnam, &       in etiology, course, treatment response, and
Farr, 1988). According to most estimates, 25%       outcome. For example, people diagnosed with
to 30% of homeless individuals have severe          paranoid schizophrenia are thought to have a
mental illness (Harvard Medical School, 1992).      later onset and better prognosis, whereas indi-
A 1992 survey of American jails reported that       viduals diagnosed with the disorganized sub-
7.2% of the inmates were seriously mentally ill     type tend to have an earlier onset, poor
with acute symptoms. A shocking 29% of the          premorbid functioning, and a less significant
jails acknowledged holding these individuals        remission or recovery.
without any charges against them, often await-         Many individuals experience a mix of
ing a bed in a psychiatric hospital. The vast       symptoms and do not fall neatly into one of
majority of individuals with charges against        the four subtypes. For example, Schizoaffec-
them had been charged with misdemeanors             tive Disorder is the presence of both the
such as trespassing (Torrey, 1995). Without ad-     symptoms characteristic of schizophrenia
equate resources, these individuals are more        and of a concurrent mood disorder. Individu-
likely to become victimized by engaging in un-      als with schizotypal Personality Disorder,
safe sexual practices (AIDS) or using and abus-     though experiencing milder symptoms, func-
ing drugs and alcohol. Indeed, data from the        tion only marginally better than patients
National Institute of Mental Health’s (NIMH)        with schizophrenia. A significant number of
Epidemiologic Catchment Area Survey of 1992         individuals who have Schizotypal Personality
established a lifetime rate of substance abuse      Disorder at a younger age gradually develop
among people with schizophrenia at 47% (Har-        Schizophrenia or Schizoaffective Disorder
vard Medical School, 1995).                         later in life (Mueser & Gingerich, 1994).
    The suicide rate in the general population is
around 1%; it is 10% to 13% for individuals di-
                                                    Identifying the Illness
agnosed with schizophrenia (Caldwell &
Gottesman, 1990; Roy, 1992). A staggering 50%       Schizophrenia is a complex and confusing ill-
of people with schizophrenia attempt suicide        ness for mental health professionals, family
at one point in their lives (Mueser & Glynn,        members, and patients. It is an episodic and
1993). Suicide is also the most frequent cause      unpredictable illness with symptoms that vary
of premature death for individuals with             in intensity at different times during its
schizophrenia (Saarinen, Lehtonen, & Lon-           course. The specific symptoms of schizophre-
nqvist, 1999). According to the NIMH, an addi-      nia are well documented, including the pres-
tional 20% of individuals with untreated            ence of positive symptoms, negative symptoms,
Bipolar Disorder die of suicide; 75% of these       or both. The positive symptoms of schizophre-
victims are men.                                    nia describe the presence of hallucinations,
                                     21 • SCHIZOPHRENIA AND SEVERE MENTAL ILLNESS                     145

delusions, loose associations, disordered think-       indicating the onset of severe mental illness
ing, and impairment in reality testing. The neg-       include dramatic changes in sleep pattern, se-
ative symptoms include affective flattening (a         vere depression, confused thinking, and ex-
restriction in the range and intensity of emo-         treme highs and lows (Carter, 1994). The
tional response), alogia (poverty of speech and        individual may sleep less, or more, or at un-
content), and avolition, or non-goal-directed          usual times. As Torrey (1995) states, “Some pa-
behavior (Andreasen & Olsen, 1982). Severe             tients simply begin talking in a vague way in
negative symptoms are strongly associated              the early stages of their illness, with tangential
with poor social functioning and are relatively        thoughts that sound almost, but not quite, log-
stable over time (Mueser & Glynn, 1993). Cog-          ical” (p. 96). An early and accurate diagnosis of
nitive disorganization (confused thought and           mental illness is critical, as there is evidence to
speech) has at times been regarded as both a           suggest that long delays in treating early
positive and negative symptom, as well as              episodes of schizophrenia contribute to a poor
being in a distinct category of its own (Harvard       outcome (Wiersma, Nienhaus, Slooff, & Giel,
Medical School, 1995).                                 1998). Recent studies indicate that individuals
    Symptoms of all of the schizophrenia spec-         who receive no drug therapy during their first
trum disorders are most likely to appear from          psychotic episode will spend more time in
late adolescence to the late twenties, with the        mental hospitals during the next three to five
emergence of symptoms in males generally ap-           years (Harvard Medical School, 1995).
pearing earlier than in females (Angermeyer &
Kuhn, 1988; Kopelowicz & Liberman, 1998).
There is a form of late-onset schizophrenia            THE ROLE OF THE COUNSELOR
that begins after the age of 40. The exact inci-
dence of late-onset schizophrenia is unclear,          Many mental health professionals are led to
but it is not rare (Torrey, 1995). Clinically, late-   believe that there is no role for counseling and
onset schizophrenia is similar to the other            psychotherapy in the treatment of people with
schizophrenias except for the fact that more fe-       mental illness (Fenton & McGlashon, 1997;
males than males are affected. It is generally         Hellkamp, 1993; Kates & Rockland, 1994). This
believed that childhood schizophrenia also re-         is probably one result of the stigma still sur-
sembles the adult disease, although it is much         rounding these illnesses. Nonetheless, there
more rare. Only 2% of individuals with schizo-         are a number of critical roles for counselors in
phrenia have the onset of their disease in             the treatment of mental illness, including work
childhood, with two males affected for every           with the individuals who experience the ill-
one female (Torrey, 1995). However, in the             ness as well as with the family members af-
United States, nearly 75% of individuals with          fected by it. Moreover, there is evidence that a
schizophrenia experience their first symptoms          therapeutic relationship, when used in addi-
between the ages of 17 and 25.                         tion to drug therapy, is helpful in reducing the
    Just prior to an initial psychotic break, indi-    rehospitalization rate for schizophrenia (Fen-
viduals can experience a prodromal phase to            ton & McGlashon, 1997; Hogarty et al., 1995;
their illness. During this period of time, there       Kopelowicz & Liberman, 1998; Rapp, 1998).
is a growing deterioration in the functioning              One critical role for the counselor is that of
of the individual, increased eccentricity, odd         making an accurate differential diagnosis.
ideation, and withdrawal from others (Mueser           Prior to diagnosing a client with schizophrenia
& Glynn, 1993). Counselors who do not spe-             or other psychotic disorder, other physical ill-
cialize in the treatment of severe mental illness      nesses should first be ruled out by the treating
should be aware of these early signs of mental         medical professional (Kopelowicz & Liberman,
illness in some people. Increasingly bizarre,          1998; Torrey, 1995). Some of the most common
withdrawn, or paranoid behavior on the part            illnesses that can mimic symptoms of schizo-
of a young adult who presents for individual or        phrenia include tumors of the pituitary gland,
marital counseling may denote the early signs          viral encephalitis, temporal lobe epilepsy, cere-
of an emerging mental illness. Other signs             bral syphilis, multiple sclerosis, Huntington’s
146     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

disease, and, most recently, AIDS. The most ef-     client, the family, and the counselor benefit
fective way to rule out these diseases is by re-    from being part of a larger team of profession-
ferring the patient for a complete diagnostic       als. The vast majority of individuals with se-
workup, including basic laboratory work             vere mental illness are referred to many
( blood count, urinalysis), a neurological exami-   different agencies to access the services they
nation, an MRI scan, a mental health exam, and      need (Harvard Medical School, 1995; Mueser
psychological tests.                                & Gingerich, 1994). These agencies and organi-
    Childbirth can also lead to severe depres-      zations are frequently governed and funded by
sion in a minority of women. Once in approx-        different local, state, and federal bodies, who
imately 1,000 births, a new mother can              in turn may or may not have any relationship
develop schizophrenia-like symptoms. These          with each other. For the most part, this trans-
symptoms typically develop three to seven           lates into poor communication among agencies
days postpartum and dissipate rather quickly        on behalf of any particular client, and clients
with appropriate medication (Torrey, 1995).         as well as family members frequently lose
This disorder appears related to schizophre-        their way working through this tangled web.
nia in its biochemical and hormonal proper-             Case management services were designed
ties, but is not considered to be a form of         in part to address these challenges. Case man-
schizophrenia. Most women recover within            agers, also known as community support
two weeks of onset.                                 workers, typically work out of community
    A number of street drugs will also cause an     mental health centers that were developed in
individual to experience psychotic symptoms         the 1960s to address the needs of patients dis-
that may be difficult to differentiate from         charged from state institutions (Mueser,
thought disorders such as schizophrenia and         Bond, Drake, & Resnick, 1998; Rapp, 1998;
Bipolar Disorder (Rosenthal & Miner, 1997).         Rapp & Chamberlain, 1985). Case managers
Drugs such as LSD, PCP, and amphetamines            are responsible for addressing the social and
such as speed will produce hallucinations,          medical needs of their clients as well as coordi-
delusions, and disorders of thinking. It can be     nating and monitoring overall treatment
difficult to accurately diagnose an individual      (Mueser & Gingerich, 1994). Case managers
before the presence of these substances com-        also refer clients to appropriate housing and to
pletely leaves the body. Even then, such as with    agencies that can assist with financial and
amphetamine psychosis, recurrent psychotic          medical benefits, such as the Social Security
symptoms may be observed many months after          Administration and Medicare. Case manage-
the last use of the drug (Kopelowicz & Liber-       ment services also provide direct assistance
man, 1998). Prescription drugs have also been       with managing the client’s illness, including
known to cause symptoms that mimic schizo-          medication monitoring, family education, and
phrenia and other disorders. Side effects of cer-   assistance with the tasks of daily living
tain medications in some individuals can            (Kopelowicz & Liberman, 1998). Thus, it is im-
include depression, hallucinations, and para-       perative that the case manager work collabora-
noid delusions. In most cases, these side effects   tively with the patient and the other members
appear when a new drug is introduced and will       of the treatment team such as the counselor,
quickly disappear when the drug is discontin-       psychiatrist, and vocational specialist.
ued (Torrey, 1995). A thorough medical evalua-          Recent research on treating severe mental
tion and physical should help clarify the origin    illness includes an understanding of these ill-
of these symptoms in most cases.                    nesses that takes into consideration an inter-
    It is generally considered sound clinical       active developmental perspective (Strauss,
practice to work as one member of an interdis-      1989). This way of looking at mental illness
ciplinary team in the treatment of severe men-      seeks not only to understand how the illness
tal illness (Hellkamp, 1993; Kopelowicz &           unfolds, but also how the illness is affected
Liberman, 1998). Given the exceedingly com-         and influenced by interaction with the envi-
plex nature of these illnesses (including bio-      ronment. Strauss suggests that individuals
logical, social, and psychological factors), the    have a relationship with their illnesses that
                                   21 • SCHIZOPHRENIA AND SEVERE MENTAL ILLNESS                   147

has the potential to influence course and out-      important. Individuals in the earliest stages of
come. As Estroff (1989) writes, schizophrenia       their illness are generally not prepared to ad-
is an “I am” illness, one that can take over        dress the concept of chronic illness. In addi-
and define the identity of the person touched.      tion, as an intervention, counseling is generally
As a cultural anthropologist, Estroff is con-       not considered appropriate or effective with
cerned, too, that the relationships between         someone whose psychotic symptoms are not
self and sickness have not been adequately re-      well controlled with drug therapy (Kates &
searched with reference to their influence on       Rockland, 1994). As a client begins to improve
prognosis. Estroff suggests that the degree to      after an acute psychotic episode, the likelihood
which a person’s identity is eroded by schizo-      of experiencing depression increases. This de-
phrenia may rest on how the person locates or       pression comes with the realization that men-
situates the illness in relation to his or her      tal illnesses are lifelong and may impact the
sense of self. She writes, “It seems entirely       person’s previously held future life plans. Indi-
possible that for some individuals the illness      viduals in this fragile stage of recovery need to
is experienced as an object, and for others it is   be paced so as not to become overwhelmed by
more of a self-object, while for others it is in-   the enormity of what chronic mental illness
separable from the self ” (p. 194). Estroff asks    can mean for their future. Indeed, depression
a series of questions: Who and what existed         and suicide are serious threats when individu-
before the illness, and who or what endures         als with schizophrenia realize they have lost so
after? Is there an after with schizophrenia, or     many years of their lives to the illness (Carter,
only a before? Is there an identity after men-      1994; Roy, 1992; Saarinen et al., 1999). Individu-
tal illness? Is it inevitable that a person with    als who are most at risk for suicide are those
schizophrenia becomes schizophrenic? These          who have a remitting and relapsing course to
researchers propose that the ways in which          their illness, good insight (they know they are
patients and their treating professionals re-       sick), a poor response to medication, and a
spond to and address the above issues may           gross discrepancy between their earlier
significantly influence the course and out-         achievements in life and their current level of
come of these illnesses.                            functioning (Kopelowicz & Liberman, 1998;
    This type of conceptualization of the expe-     Torrey, 1995). Counselors should be particu-
rience of mental illness provides a framework       larly alert for signs of potential suicide imme-
for counselors in this field. As opposed to         diately following a relapse, when the client is
treating the biological illness itself, coun-       in a remission (Caldwell & Gottesman, 1990).
selors can serve a critical adjunctive function
by helping the ill individual adapt to the con-
                                                    Counseling Interventions
cept of having a chronic illness and its impact
on the self. As Rapp (1998) points out, one         Many different psychotherapeutic approaches
goal of supportive counseling is to encourage       have been explored for individuals with
individuals with mental illness to adopt a          severe mental illness (Hellkamp, 1993;
self-perception where the illness is “one and       Mueser & Glynn, 1993; Kopelowicz & Liber-
only one part of me” (p. 66). Rapp believes         man, 1998). In general, psychodynamic or in-
that in many instances, mental health profes-       sight-oriented counseling approaches are not
sionals and the systems in which they work          considered helpful for people with schizo-
have institutionalized low expectations for         phrenia, and may even cause greater stress for
people with mental illness. He depicts the          some (Lehman & Steinwachs, 1998; Mueser &
role of the helper as being one that empowers       Berenbaum, 1990; Mueser & Gingerich, 1994).
individuals with mental illness by being            The limited research that has been conducted
sensitive to their abilities, as well as to the     on psychodynamic therapy with this popula-
courage and resilience they have demon-             tion suggests that forms of therapy that
strated in coping with their illness.               promote regression and transference can be
    The timing of counseling in the treatment       particularly harmful to people with schizo-
of individuals with mental illness is also          phrenia (Lehman & Steinwachs, 1998). As
148     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

Fenton and McGlashon (1997) point out, the         counseling as characterized by a positive, ther-
counselor should respect the fact that ambi-       apeutic alliance, a focus on reality issues and
tious counseling interventions, when misap-        solving problems of everyday life, and encour-
plied, can cause “destabilizing cognitive          agement and education of the patients and
overload” (p. 1494).                               family for proper use of psychotropic medica-
   Conversely, individual and group therapies      tions. Supportive group counseling can also
that utilize specific combinations of support,     play a critical role in improving individual
education, and behavior and cognitive skills       functioning, social skills, quality of life, and
training should be offered over time to im-        motivation to stay on medication. Group coun-
prove functioning. These approaches should be      seling can be particularly helpful in offering
designed to address the specific deficits exhib-   support to individuals as they attempt to read-
ited in individuals with schizophrenia and         just to social life (Bellack & Mueser, 1993).
should be targeted at specific problems, such
as medication noncompliance (Lehman &
                                                   Working with Family Members
Steinwachs, 1998). Token economy systems,
though effective, have been limited in practice    The deinstitutionalization of individuals
due to ethical and legal concerns with adult       from hospital settings to the community has
patients (Mueser & Glynn, 1993).                   profoundly affected the lives of family mem-
   However, cognitive therapies, such as cog-      bers who provide care to a relative with
nitive remediation and cognitive enhance-          mental illness. Current research shows that
ment therapy, also offer promise (Hogarty          two-thirds of individuals diagnosed with
et al., 1995; Hogarty & Flesher, 1992). A re-      schizophrenia return to live with their fami-
lated technique is known as personal ther-         lies after their first hospitalization (Mueser &
apy. Personal therapy models regard mood as        Gingerich, 1994; Harvard Medical School,
a major cause of relapse and poor social ad-       1995). As informal service providers, families
justment, and attempt to reduce patient an-        have become a primary source of care for their
guish by using behavioral, educational, and        relatives. As a result, researchers and, more
supportive techniques to help individuals          recently, counselors have become interested
detect the onset of psychotic symptoms             in the family’s experience of living with a
(Hogarty et al., 1995). Cognitive remediation      mentally ill relative.
strategies focus on improving or normalizing           Families are generally unprepared for a di-
cognitive functions such as signal detection,      agnosis of severe mental illness. Unlike other
sustained attention, and memory (Green,            emotional and psychological disorders, ill-
1993; Hogarty & Flesher, 1992). One example        nesses like schizophrenia and Bipolar Disorder
of this type of therapy involves the use of so-    can emerge during the peak of a young adult’s
cial skills training where individuals are re-     successful life. Very often, these illnesses
peatedly helped to accurately perceive and         strike with little warning when individuals are
interpret social situations.                       away at college or just becoming first-time par-
   Counseling methods that are geared toward       ents. They are illnesses that evoke feelings of
the practical and attempt to teach ill individu-   disbelief, denial, guilt, loss, and anger for
als how to cope more effectively with the con-     those with the illness as well as for those close
crete problems of living appear to be most         to the ill individual. Unfortunately, for many
helpful (Kopelowicz & Liberman, 1998;              years, professionals erroneously held the fam-
Mueser & Gingerich, 1994). Torrey (1995)           ily responsible for the illness and thus intensi-
states that supportive counseling can provide a    fied the pain (Hatfield, 1982). As a result of
patient with encouragement and practical ad-       this belief, practitioners and treatment
vice, such as how to access community              providers were slow to offer family education
resources, develop social support, and mini-       or counseling to family members, who were
mize friction with family members. Kopelow-        viewed as difficult, demanding, and responsi-
icz and Liberman (1993) describe supportive        ble for their relative’s illness. In 1984,
                                    21 • SCHIZOPHRENIA AND SEVERE MENTAL ILLNESS                   149

Grunebaum wrote, “Too often family thera-            affect the health of individual family members
pists have worked in ways that have implicitly       (Hatfield, 1979; Kriesman & Joy, 1974). Promi-
blamed the family” (p. 421). The historical          nent issues related to the experience of care-
roots of this perspective permeate the litera-       giver burden are managing a mentally ill
ture throughout this century in the belief that      relative’s symptomatology and behavior; the
mental illnesses are one of the few disorders        isolation of caregivers due in part to the stigma
where “culturally transmitted hypotheses of          still attached to mental illness; the inability of
family pathogenesis” are accepted as precipi-        the patient at times to carry out the tasks of
tants of the illness (Hatfield & Lefley, 1987,       daily living; improper use of medication by the
p. 30). In the past, professional training and re-   ill person; and the tendency for family mem-
search both have relied heavily on psychogenic       bers to feel blamed by professionals for their
theories of mental illness, which attribute the      relative’s illness (Biegel et al., 1991). Families
disorder to family dysfunction.                      also feel unprepared to cope with the unpre-
   Today, the mental health field is more            dictable behavior exhibited by their relative,
knowledgeable about major psychiatric disor-         often feeling that he or she has been dis-
ders such as schizophrenia. Practitioners now        charged to the community too quickly and
know that families do not “cause” schizophre-        without adequate supports (Francell, Conn, &
nia and more readily acknowledge its biologi-        Gray, 1988; Solomon & Draine, 1995).
cal and genetic components. However,                     In many instances, because the family was
researchers and practitioners both accept that       seen as a cause of the problem, family mem-
as one aspect of the social environment, family      bers were offered psychotherapy to address
behavior has the potential to influence the          their own problematic behavior (Hatfield &
course of mental illness and perhaps even af-        Lefley, 1987; Lefley & Johnson, 1990). Al-
fect relapse rates for the identified patient        though this is no longer viewed as appropri-
(Hatfield, 1979; Lefley & Johnson, 1990;             ate or helpful to family members, there is still
Vaughn & Leff, 1985; Winefield & Burnett,            a critical role for counselors to play in the
1996). In fact, research indicates that the          lives of family members. Family members are
strongest support for effective psychothera-         in need of support in dealing with the intense
peutic treatment for schizophrenia has been          feelings of grief, guilt, and loss that accom-
for various forms of family therapy (Madanes,        pany these illnesses. They also need help in
1983; Mueser & Glynn, 1993). Randomized              making good decisions for themselves regard-
clinical trials have repeatedly demonstrated         ing when to offer help to their ill family mem-
that family interventions that provide some          ber and when it is best to offer support from
combination of illness education, support,           the background. As family caregivers age, it is
problem-solving training, and crisis interven-       also necessary to plan for the future. Coun-
tion reduce one-year relapse rates from a            selors can be helpful in assisting family mem-
range of 40% to 50% to one of 2% to 23%              bers with the emotional task of planning for
(Lehman & Steinwachs, 1998).                         the long-term care of their relative. These can
   Providing care to a family member with            be complex and difficult issues for caregivers
mental illness has some positive effects, yet it     to address without the additional support of a
can also be costly to the caregiver (Biegel,         professional.
Sales, & Schultz, 1991; Hatfield & Lefley, 1987;
Goldman, 1982; Solomon & Marcenko, 1992).
Indeed, families report that caregiving can be       CONSUMER AND FAMILY ADVOCACY
emotionally, physically, and financially bur-
densome, with some caregivers experiencing           The use of consumer providers, or case man-
high levels of depression (Biegel et al., 1991).     ager aides, represents a new and promising
Providing care and support to an individual          trend in the treatment of people with severe
with mental illness can lead to enormous             mental illness (Mowbray & Moxley, 1997).
stress and strain on the family system and           Consumer providers are individuals who
150     PART II • TREATMENT OF ADULTS WITH MENTAL AND EMOTIONAL DISORDERS

have themselves experienced severe mental         with mental illness. NAMI has been at the
illness and have been trained to provide sup-     forefront of fighting sensationalism in the
port to others who are ill. Consumers as          media about people with mental illness and
providers of mental health services are often     fighting for critical issues such as insurance
willing to undertake vital and important ef-      parity for neurobiological brain disorders.
forts to make supports accessible, usable,        Families and professionals can find out about
and effective (Mowbray, Moxley, Jasper, &         NAMI and the closest chapter to them by
Howell, 1997). There are currently numerous       going on the Internet to www.nami.org or by
consumer-run services operating around the        calling (800) 950-NAMI.
country. These include consumer-run busi-
nesses, drop-in centers, residential services,
statewide advocacy organizations, and con-        SUMMARY
sumer case management programs (Silver-
man, Blank, & Taylor, 1997). The Clubhouse,       The past 20 years have witnessed tremendous
a related model of treatment, provides social,    growth in research on the efficacy of psy-
recreational, educational, vocational, and        chotherapy for the treatment of schizophrenia
housing opportunities to individuals with         and other chronic mental illnesses (Glick
severe mental illness in a nonthreatening en-     et al., 1990; Glynn, 1990; Halford & Hayes,
vironment (Kopelowicz & Liberman, 1998).          1991; Hellkamp, 1993; Hogarty et al., 1995;
One unique aspect of this model is that it is     May, 1984; Mueser & Glynn, 1993). Family
run entirely by individuals with mental ill-      therapy, personal therapy, and supportive
ness, with minimal assistance from mental         psychotherapy models have been found to be
health professionals. A primary expectation       effective as one component of multidiscipli-
of the Clubhouse model is that everyone will      nary treatment for individuals with mental
work together to keep the program going           illness (Fenton & McGlashon, 1997; Hogarty
(Torrey, 1995). These types of opportunities      et al., 1995; Kates & Rockland, 1994; Kopelow-
provide consumers with peer support from          icz & Liberman, 1998; Mueser & Glynn, 1993).
others with similar experiences, while al-        Cognitive deficits and environmental stres-
lowing consumers to take a step forward in        sors can impose some limitations on growth
their own recovery by providing leadership        for those still struggling with basic needs,
and support to others.                            such as safe housing and affordable medical
   Services for people with serious mental ill-   care; for others, psychotherapy can be vital to
ness are not likely to improve without the or-    recovery. Fenton and McGlashon write that as
ganized input from those who have been most       clinicians, we are challenged with each indi-
affected. One goal for the mental health pro-     vidual to find “the specific combination of in-
fessional is to speak on behalf and alongside     terventions that will be most helpful for this
this vulnerable and often ignored population.     particular patient with this particular type of
The National Alliance for the Mentally Ill        schizophrenia at this particular phase of ill-
(NAMI) has emerged as one of the most visi-       ness or recovery” (p. 1495). Keeping this in
ble and influential organizations offering        mind, exciting innovations in the treatment of
leadership for individuals affected with men-     individuals with severe mental illness are
tal illness. Since its inception in 1979, NAMI    providing hope to patients, practitioners, and
has grown to over 140,000 members with 1,000      families that individuals diagnosed with
local chapters providing education, referral,     mental illness can improve both their func-
support, and advocacy to needy families.          tioning and their quality of life.
NAMI chapters throughout the country offer
family support groups and family-to-family
education programs. One strength of this or-      References
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                 1 • WELFEL UNPAGED GALLEYS   153




PART III
Diagnosis and Treatment of
Children with Mental and
Emotional Disorders
                 PREVALENCE OF
     22          CHILDHOOD DISORDERS


                 R. Elliott Ingersoll and Susan B. Previts




The notion of prevalence is common in med-               L. McQueen, September 26, 2000). Epidemio-
ical and psychological research, although the            logic research may be carried out by one or
methods used to estimate prevalence are less             two persons or in massive projects, such as
commonly explored in the professional litera-            the NIMH Epidemiologic Catchment Area
ture. Prevalence is determined through statis-           Program (Eaton & Kessler, 1985).
tical probability, and, as the mathematician                Because statistics are first and foremost a
Morris Kline (1972) noted, statistics are first          confession of ignorance, prevalence data
and foremost a confession of ignorance.                  based on statistics are always a work in prog-
The statistics with which mental health pro-             ress to be understood as “best guesses” given
fessionals estimate the prevalence of men-               available methodologies. Several problems
tal/emotional disorders are drawn from                   challenge researchers to make accurate esti-
epidemiological research. Epidemiological re-            mates regarding the prevalence of a particular
search is the study of the incidence, distribu-          disorder. First, there is a significant time lag
tion, and consequences of particular problems            between the refinement of an edition of the
in one or more specified populations as well             DSM and the gathering and analysis of data.
as factors that affect distribution of the prob-         For example, studies are still being published
lems in question (Barlow & Durand, 1999; U.S.            estimating prevalence based on DSM-III-R
Department of Health, Education, and Wel-                criteria (Kessler et al., 1997), which was re-
fare, 1978).                                             placed in 1994 by DSM-IV (which was re-
   The effort to gather accurate statistics was          placed in 2000 by DSM-IV-TR). When the
initiated by the Association of Medical Su-              DSM is updated, criteria or descriptors asso-
perintendents of American Institutions for               ciated with a disorder may change. For exam-
the Insane (later renamed the American Psy-              ple the DSM-IV added symptoms to the
chiatric Association, APA). The responsibil-             symptom list in DSM-III-R for Conduct Disor-
ity for gathering statistics was shifted to the          der (CD) (APA, 1994). The description of CD
biometrics branch of the National Institute              was again expanded in DSM-IV-TR to include
of Mental Health (NIMH) in 1949 (American                more risk factors and to discuss the relation-
Psychiatric Association, 2000a). The APA                 ship between CD and Oppositional Defiant
relies heavily on the epidemiological re-                Disorder (ODD) (APA, 2000b).
search of others for the prevalence estimates               A second problem associated with estimat-
found in the various Diagnostic and Statistical          ing prevalence has to do with the methods
Manuals (DSMs) (personal communication,                  used. As any researcher knows, some research

                                                   155
156     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

methods are better than others. There is a          contended that the conflict could not be re-
paucity of research comparing various meth-         solved because the methodologies of both
ods or data-gathering instruments (Boyle            sides are plagued with measurement error.
et al., 1997; Regier, 2000), and reported preva-        Estimating prevalence in children and ado-
lence rates may vary study by study (Regier         lescents is a relatively new undertaking. Preva-
et al., 1998). Methods of epidemiological re-       lence estimates for mental disorders in children
search on mental disorders have varied over         are further complicated by the fact that many
time. There have been three generations of          disorders thought to apply primarily or exclu-
large-scale epidemiological research using two      sively to adults (e.g., Bipolar I Disorder) are now
strategies. Each generation has used different      being applied to children (McClellan & Werry,
psychiatric nosologies and data collection tools    1997). In addition, developmental considera-
(Kohn, Dohrenwend, & Mirotznik, 1998). The          tions and comorbidity make diagnosis of chil-
first generation relied primarily on institu-       dren and adolescents much more difficult
tional records and key informants but no real       (House, 1999; U.S. Department of Health and
standardized procedures for data collection.        Human Services, 1999; also see House and
The second generation utilized structured in-       Swales, this volume). The problems of shifting
terviews in the community by nonclinical in-        criteria and refinement of data-gathering in-
terviewers that were subsequently rated by a        struments exist to a greater degree when at-
psychiatrist. The third generation (starting        tempting to estimate the prevalence of
around 1980) used clinician and trained non-        mental/emotional disorders in children (Shaf-
clinician interviewers in the community to ob-      fer et al., 1996). To add to the variables making
tain information necessary to determine the         prevalence estimates difficult to attain, the self-
presence of mental disorders as categorized in      reports of children younger than 8 or 9 years
the DSM. This present generation utilizes ex-       tend to be less reliable than those of older chil-
plicit diagnostic criteria as well as structured    dren and adults and often require corroboration
clinical interview schedules (Dohrenwend,           from adults in the children’s lives. In addition,
1998; Eaton & Kessler, 1985; Kohn et al., 1998).    children are more influenced by factors in their
Currently, all epidemiologic approaches are         immediate environment, including parent
based on personal interviews, although there        pathology, abuse, neglect, and family discord
is still controversy over the accuracy of the in-   (Kazdin, 2000).
terview method, particularly whether it is              Given these caveats, this chapter briefly
appropriate to use lay interviewers (Dohren-        summarizes some of the more common disor-
wend, 1998). Dohenwend noted, “Classifica-          ders seen in children and adolescents and the
tion systems in psychiatry have been and will       prevalence rates from the DSM and occasion-
continue to be tentative as long as disorders       ally other sources. The aim is to organize the
are grouped on the basis of signs and symp-         disorders from most to least prevalent, al-
toms elicited in interviews” (pp. 146 –147).        though this too is merely an estimation given
    Perhaps the largest problem with epidemi-       the caveats already discussed regarding preva-
ological data is summarized by Blazer and           lence rates in general. In many cases, we have
Kaplar (2000), who stated that a central con-       not found prevalence rates specific to children
flict is whether or not symptoms reported by        and adolescents and reproduced the estimated
community residents in structured inter-            lifetime prevalence rates.
views are clinically significant or not. On one         Some disorders are discussed in terms of
side of the debate, Regier (2000) noted that        point prevalence, some in terms of lifetime
the conflict could be resolved with better re-      prevalence, and some in terms of both. Point
search methods that would allow a diagnosis         prevalence refers to the estimated proportion
to be made from the results of a structured         of people in the population thought to suffer
clinical interview. On the other side, Spitzer      from the disorder at any given point in time.
(1998) and Frances (1998) have asserted that        Lifetime prevalence is an estimate at a given
data from epidemiological studies cannot re-        point in time of all individuals who have ever
place clinical judgment. Blazer and Kaplar          suffered from the disorder. Incidence refers
                                         22 • PREVALENCE OF CHILDHOOD DISORDERS                 157

to the rate of new cases in a specified period    ten Expression, accounts for approximately
of time (usually annually) (LaBruzza, 1997).      four of every five cases of LD. The prevalence
Which of these types of prevalence or inci-       of RD in the United States is estimated to be
dence data are sited depends on the availabil-    4% of schoolchildren.
ity of data. Diagnoses considered to be rare or   Attention-Deficit/ Hyperactivity Disorder (ADHD).
with little or no epidemiological data (e.g.,     The prevalence of ADHD in school-age chil-
Asperger’s syndrome) were omitted from this       dren is estimated variably at 3% to 7% (APA,
chapter. Unless otherwise noted, the preva-       2000b) and 3% to 9% (Szatmari, 1992).
lence rates cited are paraphrased from the
                                                  Expressive Language Disorder (ELD). Estimates
DSM-IV-TR (APA, 2000b).
                                                  suggest that the developmental type of ELD
Dysthymic Disorder (DD). In children, DD          may affect 3% to 5% of school-age children.
seems to occur equally in both sexes and often    There are two subtypes (acquired and develop-
results in impaired school performance and so-    mental), and the acquired type is less common.
cial interaction. Children and adolescents with
                                                  Mixed Receptive-Expressive Language Disorder
DD are usually irritable and cranky as well as
                                                  (MRELD). It is estimated that the develop-
depressed. They have low self-esteem and poor
                                                  mental type of MRELD may occur in up to 3%
skills and are pessimistic. The lifetime preva-
                                                  of school-age children but is probably less com-
lence of DD (with or without superimposed
                                                  mon than ELD.
Major Depressive Disorder) is approximately
6%. The point prevalence of DD is approxi-        Oppositional Defiant Disorder (ODD). Rates of
mately 3%. Rapoport and Ismond (1996) noted       ODD range from 2% to 16% but vary depend-
that the diagnosis is probably underutilized      ing on the nature of the population sample
with children. Keller and Russell (1996) stated   and methodology. The fact that many of the
that there have been no epidemiologic studies     symptoms may be normal developmental be-
of DD in children or adolescents.                 haviors makes diagnosis and prevalence esti-
                                                  mates of this disorder difficult (Rapoport &
Conduct Disorder (CD). Prevalence (or at least
                                                  Ismond, 1996).
the diagnosis) of CD seems to have increased
in the past 10 years and may be higher in         Developmental Coordination Disorder (DCD).
urban than in rural settings. Rates vary          Prevalence of DCD has been thought to be as
widely from 6% to 10% for males and 2% to         high as 6% for children in the age range of 5 to
9% for females. CD is one of the most fre-        11 years.
quently diagnosed conditions in all mental        Phonological Disorder (PD). For children 6 and 7
health facilities for children.                   years old, prevalence for moderate to severe
Adjustment Disorder (AD). AD may occur in         PD is estimated at approximately 2% to 3%, al-
any age group, with males and females being       though the prevalence of milder forms of the
equally affected. Prevalence rates in samples     disorder is higher. By age 17, the prevalence
of children and adolescents range from 2%         falls to 0.5%.
to 8%.                                            Mathematical Disorder (MD). The prevalence of
Learning Disorders (LDs). Estimates of the        MD is harder to establish than many other dis-
prevalence of LD range from 2% to 10%. It is      orders because many studies focus on the
thought that around 5% of students in public      prevalence of LD without separation into the
schools in the United States are identified as    specific disorders of Reading, Mathematics, or
having an LD.                                     Written Expression. The prevalence of MD
Reading Disorder (RD). “The prevalence of RD      (i.e., when not found in association with other
is difficult to establish because many studies    LD) is estimated at approximately one in every
focus on the prevalence of LD without careful     five cases of LD. It is thought that 1% of school-
separation into specific disorders of Reading,    age children have MD.
Mathematics, or Written Expression” (APA,         Sleep Terror Disorder. The prevalence of sleep
2000b, p. 52). RD, by itself or combined with     terror episodes (as opposed to Sleep Terror
Mathematics Disorder or Disorder of the Writ-     Disorder, in which there is recurrence and
158     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

distress or impairment) is estimated at 1% to         Social Phobia (SP). Epidemiological research
6% among children. There are limited data on          has reported a lifetime prevalence of SP rang-
the prevalence of the disorder in the general         ing from 3% to 13%. In children, the diagnosis
population.                                           should not be made prior to 2.5 years, as it
Sleepwalking Disorder (SD). It is estimated that      would be impossible to differentiate the symp-
between 10% and 30% of children have had at           toms from developmentally normal stranger
least one sleepwalking episode, but the preva-        anxiety. Anderson and colleagues (1987) esti-
lence of SD (marked by repeated episodes and          mated the prevalence of SP in New Zealand
impairment or distress) is far lower, in the          children to be 0.9%; Kashani and Orvaschel
range of 1% to 5%.                                    (1990) estimated a prevalence of 1% in a U.S.
                                                      cohort ages 8, 12, and 17. The median age of
Stuttering. In prepubertal children, the preva-
                                                      onset has been estimated at 12 years (Bourdon
lence of stuttering is 1% and then drops to
                                                      et al., 1988).
0.8% in adolescence.
                                                      Posttraumatic Stress Disorder (PTSD). The life-
Bipolar I Disorder. It should be noted that there
                                                      time prevalence for PTSD ranges from 1% to
is still much controversy over the prevalence of
                                                      14%, and the variability is related to the
Bipolar I Disorder among children and adoles-
                                                      methodology used and the population sam-
cents. The DSM-IV-TR estimates that around
                                                      pled. Studies of at-risk individuals (e.g., com-
10% to 15% of adolescents with recurrent
                                                      bat veterans, victims of volcanic eruption, or
Major Depressive Episodes will develop Bipo-
                                                      criminal violence) yield even broader preva-
lar I Disorder. House (1999) noted that manic
                                                      lence rates, ranging from 3% to 58%. It should
episodes (required for the diagnosis of Bipolar
                                                      be noted that PTSD is often related to child
I) are rare in children. McClellan and Werry
                                                      abuse, which is thought to be underreported
(1997) noted, “Historically considered rare,
                                                      due to issues of guilt and shame (Bremner,
childhood-onset bipolar disorder is now being
                                                      1999). Bremner notes that 16% of all women
reported more often, although its frequency
                                                      are estimated to suffer from some form of at-
remains an area of some controversy” (p. 157).
                                                      tempted or completed sexual abuse prior to
They add that currently, 20% of adult patients
                                                      their eighteenth birthday and that a consider-
with Bipolar I Disorder had their first manic
                                                      able proportion of them will develop PTSD
episode in adolescence. These authors note
                                                      prior to adulthood.
that there is still a great deal of speculation re-
garding the actual prevalence of Bipolar I in         Obsessive-Compulsive Disorder (OCD). OCD was
children and adolescents.                             previously thought to be rare in the general
                                                      population, but studies have estimated a life-
Generalized Anxiety Disorder (GAD). In com-
                                                      time prevalence of 2.5% and 10-year prevalence
munity samples, the one-year prevalence rate
                                                      of 1.5% to 2.1%. One prevalence study done
for GAD was approximately 3% and the life-
                                                      with adolescents estimated 1% prevalence (Fla-
time prevalence rate was 5%. In anxiety disor-
                                                      ment et al., 1988). General estimates of lifetime
der clinics, it is estimated that approximately
                                                      prevalence in community studies of children
12% of individuals present with GAD. There
                                                      and adolescents estimate lifetime prevalence
is limited data on GAD in children because
                                                      between 1% and 2.3%. The same studies esti-
the DSM-IV version of the disorder subsumed
                                                      mate a 1-year prevalence of 0.7% for teens and
the DSM-III-R disorder Overanxious Disorder
                                                      children. The average age of onset ranges from
of Childhood (ODC) (Bernstein & Shaw,
                                                      early adolescence to the mid-twenties.
1997). The prevalence of ODC has been esti-
mated at 2.9% (Anderson, Williams, McGee,             Cyclothymic Disorder. The reported lifetime
& Silva, 1987) to 4.6% (Costello, 1989). In a na-     prevalence of Cyclothymic Disorder is from
tional comorbidity survey, Wittchen, Zhao,            0.4% to 1%. Prevalence among clinical popu-
Kessler, and Eaton (1994) estimated a preva-          lations may range from 3% to 5%.
lence of 1.3% for males and 1.5% for females          Schizophrenia. Although Schizophrenia oc-
in a 15- to 24-year-old age group.                    curs in children, it is relatively rare, but its
                                           22 • PREVALENCE OF CHILDHOOD DISORDERS                159

occurrence increases in adolescents. Often,         the rate of occurrence of this disorder in males
prodromal signs are noted in retrospect. Be-        is approximately one-tenth of that in females.
cause the disorder tends to be chronic, inci-       Panic Disorder (PD). Numerous cross-cultural
dence rates are much lower than prevalence          epidemiological studies indicate the lifetime
rates and are estimated to be approximately 1       prevalence of PD to be between 1% and 2%.
per 10,000 per year.                                One-year prevalence rates are between 0.5%
Gender Identity Disorder (GID). There are no        and 1.5%.
recent epidemiological studies to provide           Selective Mutism (SM). SM is thought to be
data on prevalence of this disorder. European       rare; it is seen in fewer than 1% of individuals
data with access to total population statistics     assessed in the mental health settings.
and referrals suggest that roughly 1 per
                                                    Stereotypic Movement Disorder (SMD). The in-
30,000 adult males and 1 per 100,000 adult fe-
                                                    formation on SMD is limited. The disorder
males seek sex-reassignment surgery, giving
                                                    may result in self-injurious behaviors. Esti-
some vague notion of prevalence estimates.
                                                    mates of prevalence of such behaviors in indi-
Feeding Disorder of Infancy or Early Childhood.     viduals with mental retardation vary from 2%
Of all pediatric hospital admissions, 1% to 5%      to 3% in children and adolescents living in
are for failure to thrive, and as many as half of   the community.
these may reflect feeding disturbances with-
out an apparent predisposing general medical        Major Depressive Disorder (MDD). Adolescent
condition.                                          and adult females are twice as likely to suffer
                                                    from MDD (single or recurrent) than adoles-
Nightmare Disorder (ND). It is estimated that
                                                    cent and adult males. In prepubertal children,
between 10% and 15% of children ages 3 to 5
                                                    boys are more likely than girls to be affected
have nightmares of sufficient intensity to dis-
                                                    (Cyranowski, Frank, Young, & Shear, 2000).
turb their parents, but the prevalence of ND
                                                    Studies of MDD report a wide range of values
is not known (Rapoport & Ismond, 1996).
                                                    for the prevalence in adult populations.
Enuresis. The prevalence of Enuresis decreases
                                                    Specific Phobia (SP). It is difficult to estimate
as children age. At age 5 years, the prevalence
                                                    the prevalence of SP in adults and children be-
is 7% for males and 3% for females; at 10 years,
                                                    cause, although relatively common, this disor-
the prevalence is 3% for males and 2% for fe-
                                                    der must cause marked distress or impairment
males; at 18 years, the prevalence is 1% for
                                                    to warrant the diagnosis. Lifetime prevalence
males and lower among females.
                                                    rates range between 7.2% and 11.3%. There are
Encopresis. Approximately 1% of 5-year-olds         no prevalence rates specific to children and
have Encopresis, and the disorder is appar-         adolescents.
ently more common in males than in females.         Autistic Disorder. In epidemiological studies
Anorexia   Nervosa     (AN). Epidemiological        of Autistic Disorder, it is estimated that be-
studies among females in late adolescence           tween 2 and 20 of every 10,000 children will
and early adulthood have found rates of 0.5%        be afflicted. The median is 5 children per
to 1% that meet full criteria for AN. Individ-      10,000.
uals whose symptoms fall below the thresh-          Substance Use Disorders (SUDs). The use of psy-
old for the disorder (e.g., Eating Disorder         choactive substances is common among adoles-
NOS) are commonly encountered. There are            cents, with 90% reporting having used alcohol
limited data concerning the prevalence of           and over 40% reporting having used an illicit
this disorder in males. The overall incidence       substance (Newcomb & Bentler, 1988). A Uni-
of AN appears to have increased in recent           versity of Michigan survey (1995) indicated
decades.                                            that substance use has increased substantially
Bulimia Nervosa (BN). Among adolescent and          since 1991. There are no large-scale epidemio-
young adult females, the prevalence of BN is        logical surveys to indicate the level of SUDs in
approximately 1% to 3%. It is estimated that        adolescents, but in community surveys, the
160     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

lifetime prevalence of alcohol abuse or de-       1996 estimate that the highest use is in the
pendence has ranged from 5.3% in 15-year-         18- to 25-year-old cohort (11%), with 12- to
olds to 32.4% in 17- to 19-year-olds (Bukstein,   17-year-olds reporting the most use in the
1997). The current emotional climate around       past year (4%).
substance abuse and the legal complications       Nicotine-Related Disorders. Nicotine intake is
may make it difficult to obtain accurate esti-    thought to typically begin in early adoles-
mates of prevalence. Where there are estimates    cence, with 95% of those who continue to
for specific substance use in children or ado-    smoke at age 20 becoming regular smokers. In
lescents in the DSM-IV-TR, those are summa-       1996, use in the past year was highest in the
rized below. It should be noted that although     18- to 25-year-old cohort (45%).
each subcategory below bears the generic label
                                                  Opioid-Related Disorders. A 1997 survey of use
for disorders related to a substance, for most
                                                  among high school students estimated that
subcategories, all we have are estimates of use
                                                  about 2% of high school seniors had ever used
that give us no clue as to how many users
                                                  heroin, and 10% reported inappropriate use of
would meet the criteria for abuse or depend-
                                                  other analgesics.
ence. For further caveats to the prevalence of
substance use and dependence in general, see      Phencyclidine-Related Disorders. According to
Ingersoll and Burns (this volume).                1996 data, 3% of Americans 12 years old and
                                                  older report ever using phencyclidine. The
Alcohol-Related Disorders. The first episode
                                                  highest proportion using phencyclidine in the
of alcohol intoxication is likely to occur in
                                                  prior year was 12- to 17-year-olds (0.7%).
adolescence.
                                                  Sedative, Hypnotic, or Anxiolytic-Related Disor-
Amphetamine-Related Disorders. A 1997 survey
                                                  ders. More than 15% of Americans use these
of high school seniors (APA, 2000b) estimated
                                                  medications in any given year. Most take as di-
that 16% had ever used amphetamines, with
                                                  rected without any misuse, but 1996 data esti-
10% having used in the prior year. It is as-
                                                  mate that 6% of Americans have ever taken
sumed that the purpose of the use in these in-
                                                  these drugs illicitly. The age group with the
stances was to get “high,” as opposed to a
                                                  highest estimated illicit use was 26- to 34-year-
prescribed use like that for ADHD. A diagnosis
                                                  olds (3% using “sedatives” and 6% using “tran-
of ADHD does increase the risk of substance
                                                  quilizers”). Those ages 18 to 25 were most
abuse but treatment with stimulant medica-
                                                  likely to have used illicitly in the prior year.
tion does not increase this risk (Greenhill,
1998).
Cannabis-Related Disorders. A 1995 survey esti-   References
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                    DIAGNOSTIC EVALUATION OF
      23            MENTAL AND EMOTIONAL
                    DISORDERS OF CHILDHOOD


                    Thomas P. Swales




A wide variety of assessment methods                     • Is there a diagnosis from the Diagnostic and
and instruments are appropriate for use                    Statistical Manual of Mental Disorders (DSM-
with children, including self-report and in-               IV-TR) provided for each patient?
terviewer-based instruments, parent and                  • Did you document that you screened for
teacher questionnaires, and observational                  other childhood psychiatric disorders be-
systems. The most reliable and valid ap-                   yond what was diagnosed?
proach to assessing children for psychiatric
disorders incorporates all of these methods              • In reading your notes, would someone find
into a multimodal assessment.                              clear examples of how you determined that
   Before you begin reading this chapter, pull             specific diagnostic criteria were met based
two or three charts from your clinical practice            on specific examples from the parent and
and review them carefully, as if the diagnoses             child interviews?
you made were being challenged. Try to an-               • Was information obtained from the child’s
swer the following questions:                              teacher and physician?
             23 • DIAGNOSTIC EVALUATION OF MENTAL AND EMOTIONAL DISORDERS                       163

• How did you monitor improvement (or              meaningful communication among mental
  worsening) in the course of treatment,           health professionals. The DSM section on dis-
  across sessions?                                 orders usually diagnosed in childhood or ado-
                                                   lescence lists the following diagnoses: mental
The objective of this chapter is to provide        retardation, learning disorders, motor skills
you with guidelines and resources for im-          disorders, communication disorders, pervasive
proving how you evaluate and diagnose chil-        developmental disorders, attention-deficit and
dren and adolescents with mental and               disruptive behavior disorders, feeding and eat-
emotional disorders.                               ing disorders, tic disorders, elimination disor-
    Any diagnostic interview with children         ders, and other disorders. Mental health
or adolescents must include a comprehensive        counselors should obtain a history of all of
medical, developmental, and social history,        these during their diagnostic interview and
typically obtained through interview with the      refer for appropriate psychological and med-
parents. An accurate history provides a base       ical evaluation. However, it is also important
for understanding the presenting problems in       that other conditions be routinely screened,
the context of a child’s life and reveals poten-   including mood disorders, anxiety disorders,
tial areas for intervention. Medical history is    Schizophrenia, substance use disorders, and
important because it may reveal preexisting or     problems related to abuse or neglect. For ex-
comorbid factors contributing to behavior          ample, histories of substance abuse, mood dis-
problems. A medical history should include         orders, and psychosis must be carefully
identification of any major physical problems      explored when working with adolescents.
(head injuries, seizures, infections), past med-
ical or psychiatric hospitalizations, and any
prolonged use of medication. Perinatal history     ASSESSMENT TOOLS THAT
should also be explored for prenatal infection     FACILITATE DIAGNOSIS
or substance abuse, delivery complications,
or maternal illness. A developmental history       Structured and semistructured interviews
can reveal an experience of delays in language     have been written to diagnose psychiatric dis-
or motor functioning or past treatment for         orders in children and adolescents, although
these problems. A social history is complete       these are primarily used in research studies.
when it includes information about peer            In these interviews, specific questions are
relationships, participation in group organiza-    asked of parents and/or children to elicit suffi-
tions, sports and activities, and parental atti-   cient information to determine whether or not
tude toward discipline and its effectiveness.      a specific symptom was present. In structured
An educational history not only reveals aca-       interviews, patients are asked specific ques-
demic performance, but also indicates the per-     tions that are often read exactly as written,
vasiveness of the problems reported by the         with limited responses typically of yes or no.
parents in the home. Children should also be       The National Institute of Mental Health Diag-
asked what they like and don’t like about          nostic Interview Schedule for Children is per-
school, and what kinds of problems they are        haps the best-recognized structured interview.
experiencing there. A family history (often        This interview can be administered by com-
overlooked) should encompass information re-       puter, but the scope of its approximately 3,000
garding medical, neurological, or psychiatric      questions would be unrealistic to apply to a
disorders and substance abuse problems.            real-world clinical setting (DISC-IV; Shaffer,
    All mental health professionals rely on the    Fisher, & Lucas, 1999).
diagnostic criteria in DSM-IV-TR (American            In contrast interviews that are semistruc-
Psychiatric Association, 2000) to diagnose         tured reflect a more real-world clinical pro-
childhood psychiatric disorders. The diagnos-      cess. These interviews provide open-ended
tic criteria in the DSM also provide a nomen-      questions and allow for further questions to
clature and common language that promote           clarify contradictions or confusion (Angold &
164     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

Fisher, 1999). The interviewer has to make          according to DSM-IV, the first symptom in a
clinical judgments regarding which questions        major depressive episode is a depressed mood
to ask based on the child’s developmental age,      for most of the day, nearly every day, for two
gender, and cultural background. The Kiddie         weeks or more. It may make sense to ask ques-
Schedule for Affective Disorders in School-         tions of both the parent and child, such as:
Age Children (K-SADS; Orvaschel, 1995; Or-          How have you been feeling lately? Have you
vaschel, Puig-Antich, Chambers, Tabrizi, &          been feeling sad, down, or cranky? How long
Johnson, 1982) is an excellent example of a         does it last? How many days have you felt de-
semistructured interview. Structured inter-         pressed? Do you feel sad most of the day?
views are a clear reminder that there is logic in   These are all examples of follow-up questions
decision making in assessing childhood psy-         that help the mental health professional gauge
chiatric disorders; semistructured interviews       a depressed mood. Counselors often overlook
highlight the importance of asking the right        asking adolescents if they have felt mad, irrita-
question to elicit a meaningful response. Semi-     ble, or cranky, all of which are also signs of
structured interviews model best practices.         depression or Bipolar Disorder. It is also im-
Mental health counselors can improve their di-      portant to ask if there were other times when
agnostic skills, especially during training, by     they felt depressed for days on end, and to find
examining these interviews.                         out the longest period when they were de-
    All diagnostic interviewing involving chil-     pressed. The second symptom in a major de-
dren and adolescents must consider the course       pressive episode is a markedly diminished
and timing of symptoms across the develop-          interest or pleasure in daily activities. To as-
mental life span. For example, if symptoms          sess this feature, practitioners should ask what
date back to the preschool years involving inat-    the child usually does for fun during free time,
tention, distractibility, and hyperactivity, then   and if things have changed or become boring:
it is important to rule out ADHD. In contrast, a    Have you ever had times in the past when you
rapid onset of problems with no prior difficul-     lost interest in most things that you enjoy? Do
ties could raise the possibility of a depressive    you know why you have become depressed or
disorder. Even the typical format of a semi-        lost interest in most things?
structured interview involves gathering back-          Given the wide range of possible psychi-
ground information about developmental and          atric disorders involving children and adoles-
medical history. Typically, information is          cents and the high rate of comorbidity, it is
gathered about the child’s school, peer rela-       important to include in each evaluation a
tionships, hobbies and interests, and family        broad survey of possible problems. Behavior
relationships. This allows for rapport building     checklists completed by the child’s parents
and also helps the interviewer to place the         and teachers are often a first step in screen-
child at ease. Second, past treatment is re-        ing for childhood psychiatric disorders. Not
viewed, including any medical conditions or         only do these checklists provide some infor-
legal involvement. Third, specific questions        mation on possible problems, but they also
are asked to screen for Major Depression and        quantify how children compare to others of
other mood disorders, Schizophrenia and             similar age and gender. There are many excel-
other psychotic disorders, anxiety disorders,       lent checklists available, but the most com-
and attention-deficit and disruptive behavior       monly used checklist in clinical settings is the
disorders.                                          Achenbach Child Behavior Checklist and
    It does not make sense for mental health        Teacher Report Form (CBCL, TRF; Achen-
counselors to read the DSM-IV diagnostic cri-       bach, 1991). Items on the Achenbach are com-
teria word-for-word. Semistructured inter-          pleted for the present time and over the prior
views indicate the importance of asking             two months, and are rated on a 3-point scale
several questions of a parent or child to deter-    where 2 = Very true or often true, 1 = Some-
mine if a particular symptom is present and         what or sometimes true, and 0 = Not true.
the severity of the problem. For example,           However, it is important to keep in mind that
             23 • DIAGNOSTIC EVALUATION OF MENTAL AND EMOTIONAL DISORDERS                      165

the questions on any checklist are often          Pervasive Developmental Disorders
briefly worded, and as a result, the response
                                                  Pervasive developmental disorders such as
may be incomplete. For example, a question
                                                  Autism are characterized by severe and perva-
worded “Often fidgets” could be interpreted
                                                  sive impairment in social interaction and com-
by the reader to refer to fidgeting with hands
                                                  munication, accompanied by abnormal activity
but perhaps not squirming in a chair. Screen-
                                                  and interests, and typically presents before
ing checklists are helpful and important
                                                  age 3. Neurological and medical disorders are
sources of information, but they do not substi-
                                                  common, as well as mental retardation. A vari-
tute for a thorough clinical interview of the
                                                  ety of questionnaires and semistructured in-
parents and child separately. These checklists
                                                  terviews are available (Trevarthen, Aitken,
can indicate areas for further interview in
                                                  Papoudi, & Roberts, 1996). However, behav-
subsequent sessions.
                                                  ioral observation is often key, and referrals are
                                                  commonly made for psychological evaluation.
                                                  To assist clinical observation, instruments
APPROACHES TO DIAGNOSIS FOR SPECIFIC
                                                  such as the Childhood Autism Rating Scales
CHILDHOOD DISORDERS
                                                  (Schopler, Reicher, DeVellis, & Daly, 1980) are
                                                  often used to document symptoms and sever-
Unfortunately, there is no one diagnostic in-
                                                  ity. Mental health counselors frequently ob-
terview that can work well with all childhood
                                                  serve that these children are detached and
disorders. Mental health counselors must be
                                                  aloof and may ignore greetings. Language may
prepared to change or modify their standard
                                                  be absent or odd. Physically, the child may
evaluation practice to address the problem at
                                                  hand-flap, toe-walk, and rock, and may react
hand. Additional guidelines are provided for
                                                  oddly to tactile or other stimulation.
several highlighted disorders that demon-
strate the importance of:

                                                  Attention-Deficit /Hyperactivity Disorder
• Making direct behavioral observations
  (e.g., pervasive developmental disorders).      ADHD is characterized by both inattention
• Obtaining teacher report (e.g., Attention-      and hyperactivity-impulsivity present before
  Deficit/Hyperactivity Disorder).                age 7 and causing significant impairment in
• Interviewing the parents separately (e.g.,      multiple settings. For example, teachers often
  Conduct Disorder).                              report that the child is having difficulty in the
• Using medical laboratory measures (e.g.,        classroom setting listening, paying attention,
  Substance Abuse and Dependence).                and completing work. Hyperactivity may also
• Thoroughly screening the patient for symp-      be present, characterized by physical restless-
  toms of psychosis or medical problems,          ness and constantly being on the go. In the di-
  which warrant immediate attention (e.g.,        agnostic evaluation for ADHD, it is important
  Schizophrenia).                                 to consider how the degree of symptoms varies
• Interviewing the patient in depth (e.g.,        across situations. It is not uncommon for chil-
  mood or anxiety disorders).                     dren with ADHD to do more poorly on tasks
                                                  they find boring. Behavior checklists are par-
When faced with specific diagnostic evalua-       ticularly important in the evaluation of ADHD,
tion challenges involving disorders that are      because they provide normative data relative
outside the scope of a mental health coun-        to other children. The hyperactivity index of
selor’s usual practice, there are several gen-    the Connors Revised Parent and Teacher
eral handbooks listed in the references that      Rating Scales (Goyette, Connors, & Ulrich,
serve as excellent resources for modifying        1978) is commonly accepted as a normative-
the diagnostic evaluation (e.g., Mash &           referenced index that can help discriminate
Terdal, 1997; Netherton, Holmes, & Walker,        between children with ADHD and comparison
1999).                                            groups. The Connors is often repeated on a
166     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

weekly basis while Ritalin, Adderal, or other      disorders. There are no well-validated mea-
psychopharmacological treatment is titrated        sures to screen for substance use disorders in
by a physician to produce maximal behavioral       adolescents. Adolescents should be asked
improvement. Many consider that the most im-       specifically about any use of alcohol, mari-
portant method or “gold standard” by which         juana, cocaine, hallucinogens, opioids, in-
ADHD should be judged is direct observation        halants, and stimulants. It makes sense to
of classroom behavior (Abikoff, Gittleman-         obtain from adolescents some measure of fre-
Klein, & Klein, 1977). Others also consider lab-   quency of use (e.g., days per week or month),
oratory-based continuous performance tests         amount consumed, and how many total times
helpful. For more information on noninter-         they have used. Also, it may be helpful to use a
view-based aspects of the evaluation of ADHD,      timeline follow-back procedure, which in-
the reader is referred to Anastopoulos (1999).     volves a structured interview where daily con-
Clearly, when evaluating for ADHD, it is also      sumption is charted with the aid of a monthly
important to augment the clinical interview        calendar and special events called “memory
with information directly from the teacher.        anchor points.” During the interview, the
(For more on ADHD, see Nigg & Rappley, this        adolescent should be asked about signs of de-
volume.)                                           pendence, including any desire to cut down
                                                   or control use, time spent obtaining drugs or
                                                   recovering, loss of friends, decrease in
Disruptive Behavior Disorders
                                                   school/work performance, and mental or
Conduct Disorder is often diagnosed through        physical problems as a result of use. Labora-
parent interview simply by asking if the child     tory measures, such as urine toxicology
has been displaying any of the behaviors out-      screens obtained through the adolescent’s pe-
lined in DSM-IV. Conduct Disorder has four         diatrician, are often helpful in cross-validating
main features, which are typically easily          self-report, as well as information from peers,
elicited through parent interview. First, and      typically obtained second-hand. Poor school-
most important, is physical aggressiveness to      work or missing school because of use, driving
people or animals, which can be readily iden-      while drunk, legal consequences, or fights
tified by inquiring about frequent fights at       with friends and family should all be ex-
school or in the neighborhood with peers.          plored. The goal of treatment is to break
Also, cruelty to people or animals, as well as     through the feelings of denial associated with
use of weapons, are typically elicited through     substance dependence and to help the patient
interview. Second, destruction of property         recognize the harmful consequences of ongo-
should be explored, including firesetting and      ing use. Only with in-depth assessment can a
vandalism. Third, deceitfulness and theft can      clear picture of the harmful consequences of
also be problems, including breaking into a        use be formed.
car, house, or building, frequent lying, and
stealing from others. Fourth, serious viola-
                                                   Schizophrenia and Other Psychotic Disorders
tions of rules involving truancy from home or
school should be explored. What makes as-          All children should be screened for the pres-
sessment unique is the importance of obtain-       ence of auditory or visual hallucinations and
ing a thorough medical, developmental, and         delusions. Children with Schizophrenia gen-
social history, as well as the importance of in-   erally will present with psychotic symptoms
terviewing both parents together (Breen &          and a deterioration of overall functioning.
Altepeter, 1991).                                  Unfortunately, mental health counselors can
                                                   easily overlook inquiring about delusions
                                                   and hallucinations, with potentially tragic
Substance-Related Disorders
                                                   results. Children with early-onset Bipolar
Unfortunately, these disorders are all too com-    Disorder may also present with psychotic
mon among adolescents with other psychiatric       symptoms, and at times can be misdiagnosed
             23 • DIAGNOSTIC EVALUATION OF MENTAL AND EMOTIONAL DISORDERS                      167

as having Conduct Disorder. In situations          disorder requires that there be “clinically sig-
where there is indication of psychosis, a psy-     nificant impairment or stress.”
chiatric evaluation is clearly indicated to aid       Determining the severity of a problem is a
both in diagnosis and treatment (Werry, Mc-        difficult clinical judgment. Anxiety disor-
Clellan, & Chard, 1991). During the inter-         ders are a good example of the challenges in
view, children should be asked if they have        diagnostic evaluation, but the entire spec-
ever heard noises that other people couldn’t       trum of childhood disorders is filled with
hear, such as the voices of people whispering      the same difficulties. The best strategy to
or talking, or seen something that no one          deal with this is to obtain information from
else could see, such as a person. It is impor-     multiple sources beyond the child, including
tant to determine if the child was awake at        the child’s family and teachers. With anxiety
the time and to also consider the child’s age;     disorders in particular, it is also important to
preschoolers often have imaginary friends.         ask questions to determine if the problem is
They should also be asked if others are con-       unremitting or characteristic of a younger
spiring against them or trying to hurt or poi-     child.
son them.                                             To avoid overdiagnosis of Obsessive-
                                                   Compulsive Disorder and other anxiety dis-
                                                   orders, semistructured interviews have also
Depressive Disorders
                                                   been developed for anxiety disorders in chil-
Children and adolescents may provide more          dren, such as the Anxiety Disorders Inter-
information about symptoms of depression           view Schedule for DSM-IV, Child Version
than would be obtained through interview           (ADIS-C; Silverman & Nelles, 1988). In this
with the parents. All children will experience     instrument, a feelings thermometer is used
periods of sadness or unhappiness as a result      as a visual prompt to assist younger children
of specific environmental or internal factors.     in rating their fear or distress. Self-report
Clearly, structured interviews highlight the       anxiety scales, such as the Multidimen-
importance of identifying depressive disor-        sional Anxiety Scale for Children, can also
ders in children and adolescents by conduct-       be helpful in monitoring change over the
ing a thorough and in-depth interview (see         course of treat ment (MASC; March, Parker,
previous). Numerous self-report checklists,        Sullivan, Stallings, & Connors, 1997). For an
such as the Children’s Depression Inventory        excellent review of assessment of childhood
(Kovacs, 1980), have been used to assist not       anxiety disorders, see March and Albano
only in the diagnostic evaluation of depres-       (1998).
sion, but also in monitoring symptom change
over time. For an excellent review of depres-
sion scales and checklists in children, see        SUMMARY
Compas (1997).
                                                   The challenges of diagnosing psychiatric
                                                   disorders in children and adolescents are
Anxiety Disorders
                                                   great. This chapter reviewed many issues in
Childhood fears and anxieties are so common        evaluating childhood psychiatric disorders,
that it is often difficult for any mental health   but in no way is that review complete and
professional to separate clinically significant    comprehensive. Additional training, super-
anxieties and fears from those that are charac-    vision, and experience in working with chil-
teristic of normal child development. Consider     dren and adolescents will be invaluable for
how common it is for a toddler to experience       those with further questions. Several recent
nightmares, or for an older child to fear          books serve as excellent references; some
heights. By what standard do we determine          have specific guidelines for interviewing
if these fears justify a psychiatric diagnosis     children with psychiatric disorders (e.g.,
and treatment? As noted in DSM-IV, a mental        Morrison & Anders, 1999) and detailed
168      PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

reviews of childhood psychiatric disorders                Breen, M.J., & Altepeter, T.S. (1990). Disruptive be-
(Mash & Terdal, 1997). Readers are encour-                    havior disorders in children: A treatment-focused
aged to consult these resources as well.                      assessment. New York: Guilford Press.
   Diagnostic evaluation of childhood psychi-             Compas, B.E. (1997). Depression in children and
atric disorders is a complex undertaking. Reli-               adolescents. In E.J. Mash & L.G. Terdal (Eds.),
                                                              Assessment of childhood disorders (pp. 197–229).
able and valid diagnostic evaluation must
                                                              New York: Guilford Press.
begin with a comprehensive and multimodal
                                                          Goyette, C.H., Connors, C.K., & Ulrich, R.F. (1978).
assessment. Subsequently, periodic reassess-                  Normative data on Revised Connors Parent
ment will also aid the mental health coun-                    and Teacher Rating Scales. Journal of Abnormal
selor in both monitoring treatment progress                   Child Psychology, 20, 221–236.
and modifying the intervention plan. When                 Kovacs, M. (1980). Rating scales to assess depres-
evaluating a child for a psychiatric disorder,                sion in school-aged children. Acta Paediatrica,
clinicians specifically should:                               46, 305 –315.
                                                          March, J.S., & Albano, A.M. (1998). New develop-
                                                              ments in assessing pediatric anxiety disor-
1. Obtain a comprehensive history.                            ders. In T.H. Ollendick & R.J. Prinz (Eds.),
2. Interview the parent and child separately.                 Advances in clinical child psychology (Vol. 20,
3. Screen for all major childhood psychiatric                 pp. 213 –241). New York: Plenum Press.
   disorders.                                             March, J.S., Parker, J., Sullivan, K., Stallings, P., &
4. Obtain detailed information about specific                 Connors, C. (1997). The Multidimensional
   symptoms that appear present, and docu-                    Anxiety Scale for Children (MASC): Factor
   ment examples in notes.                                    structure, reliability, and validity. Journal of
5. Use construct-specific instruments tailored                the American Academy of Child and Adolescent
   to the child’s diagnosis to monitor change.                Psychiatry, 36, 554 –565.
                                                          Mash, E.J., & Terdal, L.G. (1997). Assessment of
6. Obtain a second opinion when the diagno-
                                                              childhood disorders. New York: Guilford Press.
   sis is in doubt.
                                                          Morrison, J.R., & Anders, T.F. (1999). Interviewing
                                                              children and adolescents. New York: Guilford
                                                              Press.
References
                                                          Netherton, S.D., Holmes, D., & Walker, C.E. (1999).
Abikoff, H., Gittleman-Klein, R., & Klein, D.                 Child and adolescent psychological disorders: A
    (1977). Validation of a classroom observation             comprehensive textbook. New York: Oxford Uni-
    code for hyperactive children. Journal of Clini-          versity Press.
    cal and Consulting Psychology, 45, 772–783.           Orvaschel, H. (1995). Schedule for Affective Disorders
Achenbach, T.M. (1991). Manual for the Child Be-              and Schizophrenia in School-Age Children, Epi-
    havior Checklist/4–18 and 1991 profile. Burling-          demiologic version 5. Ft. Lauderdale, FL: Nova
    ton: University of Vermont, Depart ment of                Southeastern University.
    Psychiatry.                                           Orvaschel, H., Puig-Antich, J., Chambers, W.,
American Psychiatric Association. (2000). Diagnos-            Tabrizi, M.A., & Johnson, R. (1982). Retro-
    tic and statistical manual of mental disorders (4th       spective assessment of prepubertal major de-
    ed., text rev.). Washington, DC: American                 pression with the Kiddie-SADS-E. Journal of
    Psychiatric Association.                                  the American Academy of Child Psychiatry, 21,
Anastopoulos, A. (1999). Attention-deficit/hyperac-           392–397.
    tivity disorder. In S.D. Netherton, D. Holmes, &      Schaffer, D., Fisher, P.W., & Lucas, C.P. (1999). Re-
    C.E. Walker (Eds.), Child and adolescent psycho-          spondent-based interviews. In D. Schaffer,
    logical disorders: A comprehensive textbook               C.P. Lucas, & J.E. Richters (Eds.), Diagnostic
    (pp. 118–138) New York: Oxford University                 assessment of child and adolescent psychopathol-
    Press.                                                    ogy (pp. 3 –33). New York: Guilford Press.
Angold, A., & Fisher, P.W. (1999). Interviewer-           Schopler, E., Reichler, R.J., DeVellis, R.F., & Daly,
    based interviews. In D. Schaffer, C.P. Lucas, &           K. (1980). Toward objective classification of
    J.E. Richters (Eds.), Diagnostic assessment of            childhood autism: Childhood Autism Rating
    child and adolescent psychopathology (pp. 34 –64)         Scale (CARS). Journal of Autism and Develop-
    New York: Guilford Press.                                 mental Disorders, 10, 91–103.
                                                                   24 • CHILD MALTREATMENT               169

Silverman, W.K., & Nelles, W.B. (1988). The Anxi-         Werry, J.S., McClellan, J.M., & Chard, L. (1991).
     ety Disorders Interview Schedule for Chil-               Childhood and adolescent schizophrenic,
     dren. Journal of the American Academy of Child           bipolar, and schizoaffective disorders: A clin-
     and Adolescent Psychiatry, 27, 772–778.                  ical and outcome study. Journal of the American
Trevarthen, C., Aitken, K., Papoudi, D., & Roberts,           Academy of Child and Adolescent Psychiatry, 27,
     J. (1996). Children with autism: Diagnosis and in-       772–778.
     terventions to meet their needs. London: Jessica
     Kingsley.




                    CHILD
      24            MALTREATMENT
                    Treatment of Child and Adolescent Victims


                    Cindy L. Miller-Perrin


Child maltreatment is a complex social prob-              fondling, kissing, child pornography). Child
lem affecting large numbers of children each              neglect refers to deficits in the provision of a
year. According to the U.S. Department of                 child’s basic needs (e.g., inattention to health
Health and Human Services (2000), there                   care needs, inadequate supervision, inade-
were 903,000 substantiated victims of child               quate nutrition, clothing, or hygiene). Psycho-
maltreatment in 1998, for a rate of 12.9 per              logical maltreatment refers to “serious mental
1,000 children. Of these cases, child neglect             injury” or acts that communicate to a child
was the most common form of maltreatment                  that he or she is worthless, unloved, or un-
(53.5%), followed by physical abuse (22.7%),              wanted. Acts constituting psychological mal-
sexual abuse (11.5%), and psychological abuse             treatment include both emotionally neglectful
and neglect (6%). Although not all experts                behaviors (e.g., inadequate nurture or affec-
agree on the specific behaviors or events that            tion, refusal or delay in psychological care)
constitute these forms of child maltreatment,             and emotionally abusive behaviors (e.g., verbally
progress has been made in broadly defining                belittling, denigrating, threatening, or reject-
them. Physical abuse refers to the use of inap-           ing children).
propriate physical strategies (e.g., beatings,
striking a child with an object, burning a
child) resulting in substantial risk of physical          SEQUELAE ASSOCIATED WITH
or emotional harm to a child. Sexual abuse                CHILD MALTREATMENT
refers to interactions between a child and an
adult when the child is being used for the sex-           Several behaviors and problems representing
ual stimulation of the perpetrator or another             the most common potential signs of child
person (e.g., oral/anal/genital penetration,              maltreatment are presented in Table 24.1.
170        PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

TABLE 24.1 Potential Signs and Symptoms Associated with Various Forms of Child and
Adolescent Maltreat ment

                       Sexual Abuse                                                  Physical Abuse
Children                                                       Children
Physical complications: genital bleeding, pain, odors; eat-    Physical complications: bruises; head, chest, and abdomi-
  ing or sleep disturbances; somatic complaints; enuresis        nal injuries; burns; fractures
  or encopresis                                                Affective-behavioral problems: aggression; hopelessness;
Affective-behavioral problems: anxiety and fears; night-         depression; low self-esteem; fighting; noncompliance;
  mares; guilt; anger/hostility; depression; low self-           defiance; property offenses; arrests
  esteem; sexualized behavior and preoccupation (e.g.,         Cognitive deficits: decreased intellectual and cognitive
  excessive masturbation, sex play with others, sexual lan-      functioning; deficits in verbal faculty, memory, prob-
  guage, genital exposure, sexual victimization of               lem solving, perceptual-motor skills, and verbal abili-
  others); aggression; regression/immaturity; hyper-             ties; decreased reading and math skills; poor school
  activity                                                       achievement; increase in special education services
Cognitive deficits: learning difficulties; poor attention      Social deficits: delayed play skills; infant attachment
  and concentration; declining grades                            problems; poor social interaction skills, difficulty
                                                                 making friends, deficits in prosocial behaviors, and
Adolescents                                                      deficits in social competence with peers; avoidance of
Physical complications: somatic complaints; eating distur-       adults
  bance; sleep disturbance
Affective-behavioral problems: anxiety; anger; depression;     Adolescents
  guilt; suicidal ideation; low self-esteem; social with-      Antisocial behavior: violent interpersonal behavior; delin-
  drawal; self-injurious behavior; sexualized behavior;         quency; violent offenses; substance abuse
  delinquency; running away; substance abuse                   Other: attention problems; depressed school perfor-
Cognitive deficits: learning difficulties; poor concentra-      mance; increased daily stress; low self-esteem
  tion and attention; declining grades

                      Child Neglect                                           Psychological Maltreatment
Physical complications: failure to thrive                      Affective-behavioral problems: aggression; self-abusive
Affective-behavioral problems: low self-esteem; aggression;      behavior; anxiety; shame; guilt; anger and hostility;
  anger; frustration; conduct problems                           pessimism; dependency
Cognitive deficits: language deficits; academic problems;      Cognitive deficits: academic problems; deficits in cognitive
  intellectual delays; poor problem solving                      ability; poor problem solving
Social deficits: disturbed parent-child attachment and         Social deficits: insecure attachments; poor social
  interactions; deficits in prosocial behavior; social with-     adjust ment
  drawal and isolation




Although no one symptom is pathognomic of                      child maltreatment can be coded on Axis I as
child maltreatment, the presence of a constel-                 V-Codes including Physical Abuse of Child,
lation of symptoms should arouse the suspi-                    Sexual Abuse of Child, and Neglect of Child.
cion of mental health counselors. Counselors                   Adjustment Disorder is also a possible diag-
should be mindful, however, that although                      nosis. Diagnostic considerations should also
these behaviors and symptoms appear to be                      include Posttraumatic Stress Disorder (PTSD)
correlated with child maltreatment, re-                        because both sexual and physical abuse vic-
searchers have yet to determine the precise                    tims are likely to exhibit symptoms consistent
nature of causal links between abuse experi-                   with this disorder (e.g., Dubner & Motta,
ences and mental health outcomes.                              1999; McLeer, Callaghan, Henry, & Wallen,
   Because the potential sequelae of child                     1994). Other psychiatric diagnostic patterns
maltreatment can involve multiple aspects of                   commonly noted in victims of child maltreat-
functioning, many patterns of psychiatric                      ment include anxiety disorders without PTSD
symptoms can emerge, resulting in various                      symptoms, mood disorders, Conduct Disor-
diagnoses. In DSM-IV (American Psychiatric                     der, ADHD, and Oppositional Defiant Disor-
Association, 2000), problems associated with                   der (e.g., McLeer et al., 1994).
                                                            24 • CHILD MALTREATMENT                171

TREATMENT CONSIDERATIONS                            academic work and attachments (physical
                                                    abuse) or anxiety and sexualized behavior
Working with children and adolescents with an       (sexual abuse). Adolescents, on the other
abuse history involves special considerations       hand, most often demonstrate juvenile delin-
that should be addressed at the beginning of        quency, substance abuse, and low self-esteem.
treatment, including client heterogeneity, de-      These developmental differences in victim re-
velopmental issues, and potential impediments       actions to maltreatment may result from
to effective treatment.                             age-related differences in the way victims per-
                                                    ceive their abuse experiences (Miller-Perrin,
                                                    1998). Mental health counselors should take
Client Heterogeneity
                                                    such developmental differences into account
Victims of child maltreatment are a diverse         when formulating treatment approaches.
group in a number of ways. Victims differ,          Therapists should also consider develop-
for example, with regard to their preabuse          mental status when determining specific ther-
histories, the nature of their abuse experi-        apeutic interventions and techniques. Thera-
ences, familial and system responses to the         pists, for example, should talk to children in
abuse, and available social supports and cop-       language they can understand and select ap-
ing resources. In addition, child maltreat-         proaches consistent with the child’s develop-
ment victims exhibit a range of symptoms of         mental capabilities (e.g., the use of drawings
varying intensity. Some children display a          and games for younger children and verbal
variety of symptoms, whereas others demon-          discussions with older children).
strate few or a complete absence of symp-
toms. Researchers have linked these areas of
                                                    Potential Impediments to Effective Treatment
divergence and shown that factors associated
with victims and their abuse often mediate          One challenge to implementing effective
the symptoms that result (e.g., Herrenkohl,         treatment interventions with child maltreat-
Herrenkohl, Rupert, Egolf, & Lutz, 1995).           ment families is the potential for counter-
   Given such complexity, it is not surprising      transference issues. Therapists working with
that victims of child maltreatment represent a      a parent who has abused a child may have
diverse group both in terms of symptom pre-         strong negative feelings toward the parent
sentation and treatment response. As a result,      that make it difficult to remain objective and
there is no canned treatment approach that will     respond in a therapeutic manner. Counselors
be appropriate or effective for all clients. In-    may also feel uncomfortable when working
deed, not all maltreated children will require      with children who display challenging behav-
professional treatment. In addition, some re-       iors associated with their abuse experience
search shows that symptoms for some victims         (e.g., sexual behaviors toward the therapist).
diminish without therapy (Gomes-Schwartz,           In addition, studies have revealed that a sig-
Horowitz, Cardarelli, & Sauzier, 1990). Profes-     nificant number of professionals who work
sionals should consider the heterogeneity of        with victims have a history of child abuse
this treatment population when making treat-        themselves (e.g., Nuttall & Jackson, 1994).
ment decisions, paying particular attention to      These experiences might affect practitioners’
symptom presentation as well as specific pre-       views of child maltreatment and its victims,
abuse, abuse, and postabuse characteristics.        contributing to nonobjective or even distorted
                                                    perceptions of clients. Practitioners should
                                                    consult with colleagues regularly to avoid
Developmental Issues
                                                    such potential problems.
Research indicates that a child’s developmen-          Other potential challenges in working
tal status is associated with functional out-       with maltreating families are difficulties as-
comes in cases of child maltreatment (see           sociated with establishing and maintaining
Table 24.1; Becker et al., 1995). Young children,   therapeutic relationships. Maltreating par-
for example, often display difficulties with        ents, for example, may be court-ordered to
172     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

participate in treatment and therefore may          of child maltreatment. As a result, relatively
lack motivation to change their behavior. In        little is known about the success of victim-
addition, abusive parents often deny that           oriented interventions for the various forms
child maltreatment has taken place. Azar and        of child maltreatment (see Finkelhor &
Wolfe (1998) recommend reframing the prob-          Berliner, 1995; Oates & Bross, 1995). Although
lem in terms of everyday difficulties such as       the amount of research examining treatment
“trouble handling children,” “loneliness,” or       efficacy is limited, available studies suggest
“stress” to reduce defensiveness. In addition,      several approaches to intervening in cases of
mutually consensual goal setting may be an          child maltreatment. Due to the complex na-
effective means of motivating parents for           ture of child maltreatment, interventions
therapy. Special care may also be needed in         should comprise multiple components target-
developing a therapeutic relationship with          ing a variety of problem areas. In addition, be-
maltreated children and adolescents who may         cause child maltreatment most often occurs
be reluctant to interact with an adult given        within the context of the family, treatment in-
their previous history of negative interac-         terventions necessarily should focus on the
tions. Therapists should therefore be particu-      family as well as the child or adolescent vic-
larly sensitive to client issues surrounding        tim. Based on each individual client’s presen-
trust and anxiety about treatment.                  tation, mental health practitioners should
    Legal issues are another potential impedi-      attempt to incorporate several of the follow-
ment to treatment. Mandated reporting re-           ing components into a treatment plan.
sponsibilities, for example, should be raised as
early as possible in the treatment process with
                                                    Managing Thoughts and Feelings
both children and parents. A specific plan for
addressing reports to child protective services     One major goal of treatment is to help the
should be developed with the family’s input.        victim of abuse manage the negative
To help preserve the therapeutic relationship,      thoughts and emotions that often are associ-
clients should be informed before a report is       ated with child maltreatment, such as guilt,
made and given the opportunity to make the          shame, stigmatization, anger, stress, and
report themselves, with the therapist’s assis-      fear. Therapy should provide victims with
tance, if possible. A clinical follow-up to allow   the opportunity to diffuse negative feelings
families to discuss their reactions to any re-      by confronting their abuse experience in the
port of child maltreatment can also be impor-       safety of a supportive therapeutic relation-
tant to maintaining a therapeutic alliance.         ship. Older children and adolescents often
Child maltreatment also frequently includes         are able to process the abusive experience
legal issues involving the family, such as inves-   simply by discussing it with their therapists.
tigation and prosecution. Families may need to      For younger children, however, other av-
be educated about the role and procedures of        enues may be necessary, such as reenacting
local child protective services agencies. In-       the abuse through play. Regardless of the
volvement in various legal proceedings could        client’s age, it is necessary to teach strategies
be an additional stressor that families must        for managing the negative emotions that may
deal with, and therapists should be aware of        accompany the processing of the abuse, such
the ongoing and potentially stressful nature of     as relaxation training, anger management,
such proceedings for both the victim and fam-       problem-solving skills, positive coping state-
ily (Cohen & Mannarino, 1999).                      ments, gradual exposure, stress inoculation,
                                                    and the use of imagery (see Berliner & Saun-
                                                    ders, 1996; E. Deblinger, Lippmann, & Steer,
TREATMENT INTERVENTIONS                             1996). In implementing any of these strate-
                                                    gies, practitioners should be aware that
Very little research has been conducted on in-      for many victims of abuse, the tendency to
terventions with child and adolescent victims       avoid activities directed at the past abuse
                                                           24 • CHILD MALTREATMENT              173

experience (e.g., talking about the abuse, re-     important component of treatment for clients
membering aspects of the traumatic event)          with a history of child maltreatment. Neces-
can be quite strong.                               sary self-protection skills include teaching
   Another treatment objective is to provide       children to identify abuse situations, providing
clarification of victim cognitions and beliefs     them with specific responses to protect them-
that might lead to negative self-attributions.     selves from abusive encounters, and encourag-
Cognitive-behavioral approaches are fre-           ing them to disclose any abuse experiences.
quently used to help victims change their per-     Such skills are important in light of research
ceptions about being “different” as well as        that suggests that child maltreatment victims
beliefs that they are somehow to blame for the     are at increased risk for varied forms of revic-
abuse. Here, therapists often undertake some       timization (Beitchman et al., 1992). Training
form of cognitive restructuring to appropri-       children in self-protection might prevent fu-
ately relocate the responsibility of the abuse     ture abuse from occurring, contribute to the
to the offender (see Cahill, Llewelyn, & Pear-     discontinuation of abuse (e.g., via a victim’s
son, 1991; Osmond, Durham, Leggett, & Keat-        disclosure), and may enhance a child’s feelings
ing, 1998). Group therapy is a particularly        of self-efficacy and self-esteem (Berliner, 1991;
effective modality in which to counter self-       I. Deblinger, McLeer, & Henry, 1990). Thera-
denigrating beliefs and to confront issues of      pists should also be sensitive and realistic,
secrecy and stigmatization because partici-        however, about the degree of control a child
pants are able to discuss their experiences        might have in threatening situations, particu-
with peers who also have been abused (Cahill       larly those that occur in a child’s own home
et al., 1991).                                     (Cohen & Mannarino, 1999).


Reducing Problem Behavior                          Enhancing Developmental Skills

Another goal of treatment is the reduction of      Another primary objective for treatment di-
specific problem behaviors. Although such          rected at those who have experienced child
problems are often addressed through parent        maltreatment is to enhance developmental
training approaches, noted below, individual       skills (e.g., cognitive and social skills
cognitive-behavioral approaches with children      deficits). One of the most common interven-
have also been effective in reducing behavioral    tion strategies to ameliorate developmental
dysfunctions such as impulsivity, aggression,      deficits is therapeutic day treatment pro-
and sexualized behavior (e.g., Cohen & Man-        grams, which typically provide group activi-
narino, 1996; Kolko, 1996). Several other thera-   ties, opportunities for peer interactions, and
peutic modalities have demonstrated success        learning experiences to address developmen-
in reducing various problem behaviors exhib-       tal delays (Culp, Little, Letts, & Lawrence,
ited by maltreated children, including group       1991). Strategies for enhancing developmental
approaches as well as dyadic therapy, whereby      skills, such as problem solving and social
parents and children are coached to improve        skills, can also be implemented during the
parent-child interactions (e.g., Becker & Bon-     course of individual therapy (Ammerman &
ner, 1998; Urquiza & McNeil, 1996). Some pre-      Galvin, 1998). Problem-solving skills training,
liminary reports also suggest the efficacy of      for example, can teach child maltreatment
pharmacological interventions for reducing         victims to identify problem situations, gener-
problem behaviors as well as hyperarousal          ate solutions, and implement appropriate re-
(e.g., Harmon & Riggs, 1996).                      sponses. Traditional social skills training can
                                                   also be implemented, such as didactic instruc-
                                                   tion, behavioral rehearsal and role-playing,
Empowering the Child Survivor
                                                   therapist modeling, and films of peers model-
Many experts believe that prevention training      ing appropriate behavior. Others have used
in the form of self-protection skills is an        peer prompting, groups, or play therapy to
174     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

enhance social skills development (Davis &        Implementing Adjunct Treatments
Fantuzzo, 1989; Fantuzzo et al., 1988).           and Services

                                                  Practitioners should also consider implement-
Improving Parent Skills
                                                  ing various adjuncts to victim-oriented and
In treating cases of child maltreatment, men-     parent-oriented approaches when treating cases
tal health professionals should also consider     of child maltreatment. Because of the complex
including parent-focused interventions that       and interactive nature of child abuse and neg-
target the parents of maltreated children.        lect, treatment interventions should address a
Most parent interventions have focused on         broad range of services not only to address indi-
physically abusive and neglectful parents and     vidual needs but to strengthen the functioning
include cognitive-behavioral approaches in        of the family embedded in a community. Given
the form of skills training (Schellenbach,        the high incidence of marital discord and sub-
1998). Such training involves:                    stance abuse that occurs in maltreating families
                                                  ( Justice & Calvert, 1990; McCurdy & Daro,
• Teaching parents about normal child devel-      1994), possible adjuncts to treatment include
  opmental processes to correct mispercep-        marital counseling and alcohol or drug abuse
  tions and unrealistic expectations of their     treatment. Maltreating families also are charac-
  children.                                       terized by a lack of social and economic re-
• Educating parents about the appropriate         sources. Possible interventions to enhance
  use of reinforcement and punishment in          social support include strengthening informal
  shaping child behavior and the importance       support networks, using personal networking,
  of consistency in discipline.                   volunteer linking, employing neighborhood
• Anger control techniques to reduce nega-        helpers, and social skills training (Gaudin,
  tive emotional responses and thoughts and       Wodarski, Arkinson, & Avery, 1990). Other pos-
  to enhance coping ability.                      sible adjuncts to which the practitioner should
• Education and training in stress manage-        consider referring families include employment
  ment techniques, such as relaxation train-      or economic assistance (e.g., through local ser-
  ing, stress reduction, and coping with          vice organizations, the family’s caseworker, or
  stressful parent-child interactions.            the Salvation Army), money management, home
                                                  visitation programs, support groups (e.g., Par-
   Interventions for parents who sexually         ents Anonymous), crisis hotlines, respite care
abuse their children are beyond the scope of      services, day care or preschool services (e.g.,
this chapter and the reader is referred else-     Head Start centers, therapeutic child care cen-
where for descriptions (see Chaffin, 1994). Al-   ters), and educational classes (Daro & Mc-
though less common, interventions for the         Curdy, 1994; Hay & Jones, 1994).
nonoffending parent and siblings in sexually
abusive families have been developed and          SUMMARY
typically focus on education regarding the
consequences of child sexual abuse, parental      Several forms of maltreatment have emerged
support, instruction in modeling adaptive         from the research literature, including physi-
coping for the child, instruction in parent-      cal abuse, child neglect, sexual abuse, and psycho-
child communication, and behavior manage-         logical maltreatment. Treatment for the various
ment skills training (Cohen & Mannarino,          forms of child maltreatment remains a chal-
1996; Grosz, Kempe, & Kelly, 2000). Early re-     lenge given the complex nature of child mal-
search evaluating the efficacy of such ap-        treatment and the difficulties associated with
proaches appears promising for reducing           research in this area. In attempting to address
children’s externalizing behaviors and self-      the needs of child maltreatment victims effec-
reported depression and for improving par-        tively in treatment, mental health profession-
enting skills (E. Deblinger et al., 1996).        als should be aware of the following:
                                                                    24 • CHILD MALTREATMENT                 175

• Childhood experiences of maltreatment                    Becker, J.V., & Bonner, B. (1998). Sexual and other
  frequently are associated with myriad                         abuse of children. In R.J. Morris & T.R. Kra-
  problems that may affect the physical, cog-                   tochwill (Eds.), The practice of child therapy
  nitive, social, emotional, and/or behavioral                  (pp. 367–389). Needham Heights, MA: Allyn
  functioning of children and adolescents.                      & Bacon.
                                                           Beitchman, J.H., Zucker, K.J., Hood, J.E., &
• Therapists face several challenges in work-
                                                                DaCosta, G.A. (1992). A review of the long
  ing with child maltreatment cases, includ-
                                                                term effects of child sexual abuse. Child Abuse
  ing the heterogeneity of child maltreatment                   & Neglect, 16, 101–118.
  victims, developmental considerations, and               Berliner, L. (1991). Clinical work with sexually
  special circumstances that might impede                       abused children. In C.R. Hollin & K. Howells
  treatment.                                                    (Eds.), Clinical approaches to sex offenders and
• Child-focused interventions should focus                      their victims (pp. 209–228). New York: Wiley.
  on managing thoughts and feelings, reduc-                Berliner, L., & Saunders, B.E. (1996). Treating fear
  ing problem behavior, empowering the                          and anxiety in sexually abused children: Re-
  maltreatment survivor via self-protection                     sults of a controlled 2-year follow-up study.
  skills, and enhancing developmental skills.                   Child Maltreatment, 1, 294 –309.
                                                           Cahill, C., Llewelyn, S.P., & Pearson, C. (1991).
• Parent-focused interventions should be
                                                                Treat ment of sexual abuse which occurred in
  included and should focus on education
                                                                childhood: A review. British Journal of Clinical
  about abuse, enhancement of parenting                         Psychology, 30, 1–12.
  knowledge and skills, parental support, in-              Chaffin, M. (1994). Research in action: Assessment
  struction in modeling adaptive coping and                     and treat ment of child sexual abusers. Journal
  parent-child communication, anger manage-                     of Interpersonal Violence, 9, 224 –237.
  ment, and stress reduction techniques.                   Cohen, J.A., & Mannarino, A.P. (1996). Factors that
• Several treatment adjuncts and services                       mediate treat ment outcome of sexually abused
  should also be considered when treating                       preschool children. Journal of the American
  child maltreatment families to address the                    Academy of Child and Adolescent Psychiatry, 34,
  multidimensional nature of child maltreat-                    1402–1410.
                                                           Cohen, J.A., & Mannarino, A.P. (1999). Sexual
  ment and to enhance the effectiveness of
                                                                abuse. In R.T. Ammerman, M. Hersen, & C.G.
  child- and parent-focused approaches.
                                                                Last (Eds.), Handbook of prescriptive treatments
                                                                for children and adolescents (pp. 308–329).
                                                                Needham Heights, MA: Allyn & Bacon.
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    Child abuse: New directions in prevention and




                    TREATING ANXIETY
      25            DISORDERS IN CHILDREN


                    Christopher A. Kearney and Lisa M. Linning




The concept of anxiety in children has been a            MAJOR CONSTRUCTS AND TERMINOLOGY
focus of mental health professionals for many
decades, but the study of how to treat excessive         Anxiety is a state of general apprehension and
anxiety in children has burgeoned only re-               discomfort marked by behavioral, cognitive,
cently. This chapter discusses the major con-            and physiological symptoms. Common behav-
cepts and terminology used regarding anxiety             ioral symptoms in children include avoidance,
and anxiety disorders in youth, recent find-             excessive reassurance seeking, freezing, cling-
ings that empirically support psychosocial and           ing to others, and crying. Common cognitive
pharmacological treatments for these disor-              or thought-related symptoms include exces-
ders, and recommendations for counseling in              sive worry about daily and possibly dangerous
this area. Resources for further study are also          events, irrational conclusions about oneself
included.                                                and one’s environment, and self-deprecation.
178     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

Common physiological symptoms include ac-            panic-like symptoms and avoidance must last
celerated heart rate, sweating, muscle tension,      for at least six months. Finally, Specific Phobia
nausea, stomachaches, headaches, and tremors.        is marked by unreasonable fear of a specific
A detailed listing of symptoms is available (see     object (e.g., animal) or situation (e.g., flying); a
Barrios & O’Dell, 1998).                             severe and immediate anxiety response is trig-
   The most common anxiety disorders in              gered following exposure to the phobic stimu-
children include, alphabetically, Generalized        lus. To meet diagnostic criteria for any of the
Anxiety Disorder, Obsessive-Compulsive Dis-          anxiety disorders, significant interference in
order, Panic Disorder, Posttraumatic Stress          daily functioning must be present.
Disorder, Separation Anxiety Disorder, Social
Anxiety Disorder, and Specific Phobia. How-
ever, other syndromes (e.g., Acute Stress Dis-       MAJOR FINDINGS AND QUESTIONS
order, Selective Mutism) and related problems        REGARDING TREATMENT
(e.g., school refusal behavior; see Kearney,
2001) may also apply.                                The treatment of anxiety disorders in youth
   According to the Diagnostic and Statistical       has a long history that can be divided into
Manual of Mental Disorders (DSM-IV; American         two main phases. The first phase, involving
Psychiatric Association, 1994), Generalized          study in the 1960s to 1980s, consisted of many
Anxiety Disorder is marked by excessive and          case studies and single-case experimental de-
uncontrollable worry as well as physical symp-       signs that focused on children with specific
toms (e.g., restlessness) for at least six months.   fears. The second phase, involving study in
Obsessive-Compulsive Disorder is marked by           the 1990s to the present, consists of a growing
recurrent, intrusive, bizarre, and uncontrol-        number of large-scale interventions that
lable thoughts (e.g., contamination) as well as      focus on children with different types of anx-
repetitive behaviors or rituals (e.g., handwash-     iety disorders. Both phases involve psychoso-
ing) designed to reduce distress from these          cial treatment, with a concentration on
thoughts. Panic Disorder is characterized by a       cognitive-behavioral approaches, and phar-
series of panic attacks or physical and cogni-       macological treatment, with a concentration
tive symptoms that accelerate and peak within        on anxiolytic and antidepressant medication.
10 minutes. Fear of subsequent attacks occurs        Psychosocial and pharmacological treat-
as well. Agoraphobia, or the avoidance of            ments are now discussed separately.
places where a panic attack may occur, is com-
monly associated with Panic Disorder.
                                                     Psychosocial Treatment
   Posttraumatic Stress Disorder involves the
presence of specific symptoms following expo-        Psychosocial treatment for children with anxi-
sure to an extreme stressor (e.g., assault). Key     ety disorders primarily targets the reduction
symptoms include physiological hyperarousal,         of problematic behavioral, cognitive, and phys-
avoidance of stimuli associated with the stres-      iological symptoms. The most common ap-
sor, and reexperiencing the stressor via memo-       proach involves cognitive-behavioral treatment
ries, dreams, and flashbacks. Separation             that consists of several components. These
Anxiety Disorder, the only DSM-IV anxiety            treatment components essentially include psy-
disorder specific to youth, refers to excessive      choeducation, systematic desensitization (in-
anxiety about separation from home or major          cluding relaxation training and exposure),
attachment figures (e.g., parents) for at least      flooding, response prevention, modeling and
four weeks. In addition, the child may worry         role play, cognitive restructuring, and parent-
excessively about harm to self or parents            based contingency management. Typically,
while separated. Social Anxiety Disorder             these treatments are administered in conjunc-
refers to persistent fear during interactions        tion with one another.
with or performances before other people                Psychoeducation involves educating a
(e.g., public speaking). Socially related            child about the nature of anxiety and its
                                    25 • TREATING ANXIETY DISORDERS IN CHILDREN               179

response components, and how these compo-         must be done carefully and following in-
nents interact in the child to produce an aver-   formed discussion with a client to avoid a
sive state. Children are informed about the       problematic reaction.
behavioral, cognitive, and physiological com-        Response prevention is often used with
ponents of anxiety, and asked which compo-        children with Obsessive-Compulsive Disorder
nents usually occur first in their case. In       and in conjunction with exposure. As a child is
many children, for example, physiological         exposed to whatever provokes anxiety (e.g.,
symptoms such as accelerated heart rate lead      placing hands in dirt), he or she is required to
to cognitive symptoms such as worries about       prevent ritualistic or compulsive actions (e.g.,
failure or ridicule. Such cognitions may then     handwashing) that would normally follow.
lead to behavioral avoidance, clinging to oth-    Over time, the child comes to realize that anxi-
ers, crying, or other problems. Children are      ety will decline even if no handwashing oc-
informed of how their cycle of anxiety works      curs. Response prevention may also involve the
and are shown how different treatment com-        scheduling of checking or other rituals (e.g.,
ponents address these aspects of anxiety.         certain number per hour) that allows for some
    Systematic desensitization was originally     compulsive acts but at gradually lower and
designed as a technique whereby one is grad-      lower rates.
ually exposed to fearful stimuli via imagina-        Modeling and role play are often used with
tion. Prior to such exposure, a person is         children with social anxiety and involve the
taught to relax, often by tensing and releasing   observation of others who appropriately en-
different muscle groups. This state of relax-     gage in a certain activity. For example, chil-
ation is then paired gradually with different     dren anxious about initiating conversations
anxiety-provoking scenes. A person fearful        may watch peers engage in such conversa-
of dogs, for example, would listen to con-        tions smoothly and without nervousness. The
trived scenes from a therapist regarding vari-    client may then practice these social skills
ous interactions with dogs. As the person         and interactions repeatedly in an office set-
listens to such interactions, which should in-    ting to receive feedback from a therapist.
crease anxiety, he or she induces relaxation      Eventually, as the child becomes more profi-
and, it is hoped, reduces the amount of fear      cient and less anxious, he or she would be as-
associated with the stimulus (i.e., dog). Over    signed real-life tasks such as calling friends
time, the person may listen to more anxiety-      or starting conversations with unfamiliar
provoking scenes, and relax, until no scene       children at school.
produces an aversive reaction. In vivo expo-         Cognitive restructuring targets irrational
sure is usually introduced next; here, one is     or illogical conclusions that anxious children
gradually exposed to real-life situations in-     often draw about themselves or their environ-
volving a phobic stimulus. Relaxation is          ment. For example, many children will over-
gradually paired with closer approximations       estimate the dangerousness of a situation,
to the phobic stimulus until the person can       overworry about the potential negative conse-
interact with the stimulus (e.g., pet a dog)      quences of a situation, and/or minimize their
with no problem.                                  own resources for handling a situation. Cog-
    Flooding is similar to systematic desensi-    nitive restructuring involves techniques to
tization, but usually involves initial exposure   help a child develop healthy patterns of
to the most anxiety-provoking scene without       thinking, such as realistically examining the
prior relaxation training. This approach,         evidence for one’s thought, examining plausi-
based on extinction, assumes that a person        ble alternative thoughts, and assessing one’s
will eventually experience anxiety reduction      ability to handle a situation based on past
via habituation, or getting more accustomed       performance. A child who is excessively anx-
to a stimulus. The primary advantage of           ious of failing tests, for example, can be
flooding is that it takes less time than sys-     taught that the probability of failure is small,
tematic desensitization, but the procedure        that the consequences for failure on one test
180     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

are not extreme, and that the child has a long     used prescriptive treatment to address youth
history of success on tests due to his or her      with school refusal behavior. Specifically, dif-
excellent study habits.                            ferent treatment packages were assigned on
   Contingency management is another impor-        the basis of function, or the reason why a cer-
tant component for treating children with anxi-    tain child was refusing to attend school.
ety disorders. The procedure involves training
parents and other influential adults to encour-
                                                   Pharmacological Treatment
age a child to maintain therapeutic homework
assignments, assist in exposure-based tasks, re-   Pharmacological treatments to address youth
inforce attempts to move forward in the thera-     with anxiety disorders primarily involve
peutic process, and discourage dependent and       antidepressant and anxiolytic medication. Tri-
inappropriate behaviors. For example, parents      cyclic antidepressants such as imipramine, de-
may be asked to establish a series of exposures    sipramine, and clomipramine have been used
during the week in which a child must interact     with mixed results for children with Separa-
with others. As the child does so, parents can     tion Anxiety Disorder, school refusal behavior,
monitor progress and practice skills that will     and Panic Disorder. In addition, selective sero-
help them prevent the child’s relapse in the       tonin reuptake inhibitors such as fluoxetine
future.                                            have been used with moderate success for chil-
   Recent empirical studies support the effec-     dren with obsessive-compulsive and other anx-
tiveness of these treatment components for         iety disorders. Anxiolytic medications for
children with anxiety disorders. For example,      youth with anxiety disorders primarily in-
Kendall and colleagues (1997) successfully uti-    clude benzodiazepines such as alprazolam and
lized a four-component treatment program for       clonazepam as well as buspirone. Use of these
children with anxiety disorders that focused       medications has led to moderate success in
on recognizing anxious somatic feelings,           children with Panic and Separation Anxiety
changing unrealistic cognitions or expecta-        Disorder (for reviews, see American Academy
tions, designing a coping plan, and developing     of Child and Adolescent Psychiatry, 1997; Kear-
self-reinforcement. Silverman and colleagues       ney & Silverman, 1998; Tonge, 1998).
(Silverman, Kurtines, Ginsburg, Weems, Ra-
bian, et al., 1999) also found that contingency
                                                   Major Questions
management, exposure-based cognitive self-
control, and education support were useful in      Several major questions still remain with re-
ameliorating anxiety disorders in children.        spect to treating youth with anxiety disor-
Group cognitive-behavioral treatment has also      ders. Of particular concern is knowing which
been shown to be effective (Silverman, Kur-        of the aforementioned treatment components
tines, Ginsburg, Weems, Lumpkin, et al., 1999),    is most effective for treating this population.
and family-based treatment for this population     Exposure to anxiety-provoking stimuli is cer-
has been successfully designed and tested as       tainly a key ingredient, but further work is
well (e.g., Barrett, Dadds, & Rapee, 1996).        needed to identify the best type of exposure
   A new trend in therapy for this population      for a particular child. Knowing the best way
has focused on prescriptive treatment, or          to combine exposure with other treatment
matching different types of treatment to dif-      components is crucial as well. Investigations
ferent subtypes of a particular disorder. For      of prescriptive treatment will likely enhance
example, Eisen and Silverman (1998) success-       study in this area.
fully used cognitive therapy/exposure for chil-       Another key question involves the influence
dren with more cognitively based Generalized       of therapist support. It is possible that educat-
Anxiety Disorder and relaxation training/          ing a child about anxiety and providing thera-
exposure for children with more physiologi-        pist support is enough to alleviate a child’s
cally based Generalized Anxiety Disorder. In       anxiety disorder. Evidence for this was re-
similar fashion, Kearney and Silverman (1999)      cently presented by Last, Hansen, and Franco
                                      25 • TREATING ANXIETY DISORDERS IN CHILDREN               181

(1998), who found that education/support was        easily focus on a child’s disruptive behavior,
as effective as cognitive-behavioral treatment      the identification of subtle, anxious behaviors
for youth with anxiety-based school refusal.        demands input not only from parents but also
However, support may come in the form of re-        the child and relevant others who know the
assurance to an anxious child, which may pro-       child well. In addition, assessment should in-
vide short-term but not long-term gains.            volve multiple methods of data collection,
   Another important treatment question sur-        such as interview, self-report questionnaires,
rounds the best way to prevent anxiety disor-       behavioral observation, daily ratings, and for-
ders in children. Dadds and colleagues (1997)       mal testing if appropriate. Assessment should
outlined an early intervention school-based         also concentrate on problems often associated
program that utilized cognitive-behavioral          with anxiety disorders in children, with par-
and family-based group intervention to pre-         ticular attention to depression.
vent the onset and further development of              Counselors should be aware that many
childhood anxiety disorders. Further work is        children who are anxious are reluctant to talk
necessary, however, to delineate the best ways      about their problems or engage in exposure-
of identifying and addressing the needs of          based tasks that initially raise their anxiety.
children at risk for anxiety disorders.             As such, it is important to go at a pace that is
                                                    comfortable for a child, inform the child and
                                                    parents about the rationale for a particular
RECOMMENDATIONS FOR THOSE                           task, and provide frequent encouragement,
WORKING WITH CHILDREN WITH                          reinforcement, and feedback. Early in ther-
ANXIETY DISORDERS                                   apy, this may require daily contact with a
                                                    child to assess for therapeutic compliance,
Several recommendations from empirical              school attendance, level of anxiety, and other
work can be made for counselors regarding           relevant issues.
the treatment of childhood anxiety disorders.          The treatment of anxiety in children
First, as pointed out by Kendall, Panichelli-       should also involve family members. Parents,
Mindel, Sugarman, and Callahan (1997), ther-        who may be anxious themselves, can be in-
apists who treat youth with anxiety disorders       formed of the nature of anxiety and how to
likely have to adopt several roles. First, as a     best involve their child in appropriate, inter-
consultant, the therapist endeavors to avoid        active situations. Parents should be in-
the role of expert and encourage a child to de-     structed as well not to “rescue” their child, or
velop healthy strategies to handle anxiety-         allow him or her to prematurely terminate an
provoking situations. In essence, the therapist     exposure situation (e.g., attendance at a birth-
tries to build skills to help a child become        day party). Counselors can also “test” par-
more independent and appropriate in think-          ents by providing them with a hypothetical
ing and decision making. Second, as a diag-         scenario (e.g., child refuses school due to anx-
nostician, the therapist collects information       iety) and role-playing appropriate responses.
about a child from different sources to com-           The treatment of anxiety in children often
pare the child’s functioning to normative lev-      demands some form of relapse prevention as
els, identify the primary behavior problems,        well. For example, the start of school or atten-
and design a treatment plan. Finally, as an ed-     dance at a sleepover can trigger new feelings
ucator, the therapist teaches the child about       of anxiety in some children. In these cases,
the nature of anxiety, develops the child’s         ongoing practice of what was learned in ther-
self-control, increases his or her coping skills,   apy is crucial, and booster sessions may be
and helps the child recognize his or her            scheduled with a therapist to enhance appro-
strengths as well as weaknesses.                    priate coping and decrease problematic cogni-
   Assessing different sources of information       tions or behaviors.
is important because anxiety problems are              Anxiety in children can be a debilita-
often covert in nature. Whereas many people         ting condition, but one that is amenable to
182      PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

treatment. Indeed, successful treatment of an                   Siqueland, L. (1992). Anxiety disorders in youth:
anxious child is a highly rewarding experi-                     Cognitive-behavioral interventions. Boston: Allyn
ence. However, counselors should be well                        & Bacon.
versed in the various techniques available to              Kendall, P.C., Flannery-Schroeder, E., Panichelli-
address this population, and be aware of the                    Mindel, S.M., Southam-Gerow, M., Henin, A.,
                                                                & Warman, M. (1997). Therapy for youths
rapid changes that are taking place in the field.
                                                                with anxiety disorders: A second randomized
                                                                clinical trial. Journal of Consulting and Clinical
                                                                Psychology, 65, 366 –380.
References
                                                           Kendall, P.C., Panichelli-Mindel, S.M., Sugarman,
American Academy of Child and Adolescent Psy-                   A., & Callahan, S.A. (1997). Exposure to child
     chiatry. (1997). Practice parameters for the as-           anxiety: Theory, research, and practice. Clini-
     sessment and treat ment of children and                    cal Psychology: Science and Practice, 4, 29–39.
     adolescents with anxiety disorders. Journal of        Last, C.G., Hansen, C., & Franco, N. (1998). Cogni-
     the American Academy of Child and Adolescent               tive-behavioral treat ment of school phobia.
     Psychiatry, 36, 69–84.                                     Journal of the American Academy of Child and
American Psychiatric Association. (1994). Diagnos-              Adolescent Psychiatry, 37, 404 – 411.
     tic and statistical manual of mental disorders (4th   March, J.S. (1995). Anxiety disorders in children and
     ed.). Washington, DC: Author.                              adolescents. New York: Guilford Press.
Barrett, P.M., Dadds, M.R., & Rapee, R.M. (1996).          Ollendick, T.H., King, N.J., & Yule, W. (1994). Inter-
     Family treat ment of childhood anxiety: A con-             national handbook of phobic and anxiety disorders
     trolled trial. Journal of Consulting and Clinical          in children and adolescents. New York: Plenum
     Psychology, 64, 333 –342.                                  Press.
Barrios, B.A., & O’Dell, S.L. (1998). Fears and anxi-      Silverman, W.K., & Kurtines, W.M. (1996). Anxiety
     eties. In E.J. Mash & R.A. Barkley (Eds.), Treat-          and phobic disorders: A pragmatic approach. New
     ment of childhood disorders (2nd ed., pp. 249–337).        York: Plenum Press.
     New York: Guilford Press.                             Silverman, W.K., Kurtines, W.M., Ginsburg, G.S.,
Dadds, M.R., Spence, S.H., Holland, D.E., Barrett,              Weems, C.F., Lumpkin, P.W., & Carmichael,
     P.M., & Laurens, K.R. (1997). Prevention and               D.H. (1999). Treating anxiety disorders in chil-
     early intervention for anxiety disorders: A                dren with group cognitive-behavioral therapy:
     controlled trial. Journal of Consulting and Clini-         A randomized clinical trial. Journal of Consult-
     cal Psychology, 65, 627–635.                               ing and Clinical Psychology, 67, 995 –1003.
Eisen, A.R., & Kearney, C.A. (1995). Practitioner’s        Silverman, W.K., Kurtines, W.M., Ginsburg, G.S.,
     guide to treating fear and anxiety in children and         Weems, C.F., Rabian, B., & Serafini, L.T. (1999).
     adolescents: A cognitive-behavioral approach.              Contingency management, self-control, and
     Northvale, NJ: Aronson.                                    education support in the treat ment of child-
Eisen, A.R., & Silverman, W.K. (1998). Prescriptive             hood phobic disorders: A randomized clinical
     treat ment for generalized anxiety disorder in             trial. Journal of Consulting and Clinical Psychol-
     children. Behavior Therapy, 29, 105 –121.                  ogy, 67, 675 –687.
Kearney, C.A. (2001). School refusal behavior in youth:    Tonge, B.J. (1998). Pharmacotherapy for school re-
     A functional approach to assessment and treat-             fusal. Behaviour Change, 15, 98–106.
     ment. Washington, DC: American Psychologi-
     cal Association.
Kearney, C.A., & Silverman, W.K. (1998). A critical        Resources for Further Study
     review of pharmacotherapy for youth with              Resources for further study in this area in-
     anxiety disorders: Things are not as they             clude the Web sites of the Anxiety Disorders
     seem. Journal of Anxiety Disorders, 12, 83 –102.
                                                           Association of America (www.adaa.org) and
Kearney, C.A., & Silverman, W.K. (1999). Function-
                                                           the Association for the Advancement of
     ally-based prescriptive and nonprescriptive
     treat ment for children and adolescents with
                                                           Behavior Therapy (www.aabt.org). Both or-
     school refusal behavior. Behavior Therapy, 30,        ganizations also publish fact sheets regard-
     673 –695.                                             ing anxiety disorders. Journals that contain
Kendall, P.C., Chansky, T.E., Kane, M.T., Kim, R.S.,       many articles on anxiety disorders in chil-
     Kortlander, E., Ronan, K.R., Sessa, F.M., &           dren include:
             26 • INTERVENTIONS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER                        183

Journal of Clinical Child and Adolescent Psychology    See References for books by these authors:
Journal of the American Academy of Child and Adoles-   Eisen and Kearney (1995)
     cent Psychiatry                                   Kendall et al. (1992); March (1995)
Journal of Consulting and Clinical Psychology          Ollendick, King, and Yule (1994)
Journal of Anxiety Disorders                           Silverman and Kurtines (1996)




                    INTERVENTIONS FOR
      26            ATTENTION-DEFICIT/
                    HYPERACTIVITY DISORDER


                    Joel T. Nigg and Marsha D. Rappley



Actual or suspected Attention-Deficit/Hyper-           and is the focus of this chapter. However, in-
activity Disorder (ADHD) is among the most             tervention for the hyperactive subtype would
common reasons for a school-age child to come          be nearly identical. In approaching treatment
to the attention of mental health professionals        with this population, it is almost always the
and primary care physicians (Barkley, 1998;            case that the counselor will also be facing sub-
Freid, Makuc, & Rooks, 1998). As documented            stantial comorbid problems of varying severity
elsewhere in this volume, the hallmark symp-           (Biederman, Newcorn, & Sprich, 1991). These
toms of this disorder include active behaviors         can include marked oppositional-defiant be-
that disturb classrooms and families (always           haviors that escalate to frank Conduct Disor-
on the go, can’t wait turn, interrupting) as well      der in older children, internalizing problems
as off-task behaviors and disorganization that         such as significant anxiety and/or depressive
tend to impair academic functioning. The               symptoms, academic underachievement possi-
DSM-IV (APA, 1994) provides for three sub-             bly complicated by a learning disability, and
types of this disorder. The hyperactive sub-           problematic movements or sounds in the con-
type is rare outside the preschool years and is        text of a tic disorder. Most predictive of poor
probably a precursor to the combined subtype           outcome for ADHD children, and thus impor-
in most cases (Hart, Lahey, Loeber, Applegate,         tant to target during intervention, are aggres-
& Frick, 1995). The inattentive subtype in-            sive/antisocial behaviors, peer rejection, and
cludes children who are sluggish and hypoac-           reading failure (Farrington, Loeber, & van
tive, as well as those who are overactive but          Kammen, 1990; Moffitt, 1990).
shy of cutoffs for the combined type designa-             Therefore, in formulating a treatment plan
tion (Lahey, Carlson, & Frick, 1997). The com-         for the child with ADHD, the counselor must
bined type is the most common presentation             look beyond the hallmark symptoms of the
184      PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

disorder and consider interventions that ad-             ing scales by parents and teachers (see Hin-
dress comorbid problems as well. In some                 shaw & Nigg, 1999); (3) medical examination
cases, the latter will cause the most impair-            to rule out metabolic disorders, vision and
ment for the child. Importantly, various treat-          hearing disorders, and other conditions; and
ments tend to have differential impacts on the           (4) psychological or neuropsychological ad-
symptoms of ADHD per se and on the associ-               ministration of psychometric tests to evaluate
ated difficulties.1 Options for interventions            possible learning disability or other develop-
for these children thus cover a fairly broad             mental disability. Also, the evaluating profes-
range. However, only a few interventions have            sional should have carefully considered such
demonstrated efficacy or effectiveness and               important confound conditions as depression,
feasibility in most clinical settings. For exam-         anxiety, Oppositional Defiant Disorder, and
ple, intensive “summer camp” type programs               tic disorders (Biederman et al., 1991) and such
with strict token economies may benefit chil-            potentially important situational factors as
dren with ADHD (Pelham & Hoza, 1996), but                family discord, inappropriate school place-
until this intervention is disseminated more             ment, and discrete emotional trauma. The
widely, it will be only in rare circumstances            treating counselor must review these assess-
that the counselor will find it feasible to pro-         ment records before beginning treatment. If
pose such an intervention in a general camp              the child being referred for treatment has not
setting. Thus, the most optimal interventions            had an adequate assessment by these stan-
include four broad areas of concern: adequate            dards, then one of the first orders of business
assessment, behavioral family intervention,              is to arrange for additional evaluation to as-
classroom intervention, and pharmacological              sure that the interventions being planned are
intervention. Information crucial for coun-              appropriate to the mix of problems this partic-
selors to bear in mind is noted for each of              ular child is experiencing. Once the assess-
these in turn. We then conclude with com-                ment picture is complete, a multimodal
ments on cross-discipline integration.                   intervention plan will usually be considered.



ADEQUATE ASSESSMENT
                                                         BEHAVIORAL INTERVENTIONS IN
                                                         THE FAMILY
Unfortunately, in the press of today’s health
services delivery systems, it sometimes hap-
                                                         Overview
pens that a child is diagnosed and referred for
treatment without adequate prior assessment.             There is little evidence that individual child
An adequate evaluation for ADHD should in-               psychotherapy, behavioral or otherwise, can
clude at minimum (1) careful developmental               ameliorate the core symptoms of hyperactiv-
history with the parents; (2) standardized rat-          ity/impulsivity, although recent data from the
                                                         MTA study suggest that an extremely ambi-
                                                         tious, state-of-the-art behavioral program (par-
1
 Although empirical information on treat ment of         ent training and school behavior plan) can
ADHD has been accumulating for decades, the              improve ADHD symptoms to an equivalent de-
field is currently benefiting from a large multisite,    gree with medication interventions in
multimodal study sponsored by NIMH (Richters
et al., 1995), termed the Multimodal Treat ment of
                                                         about three out of four ADHD children (MTA
ADHD Study, or MTA Study. Readers are encour-            Cooperative Work Group, 1999a). Thus, a well-
aged to peruse the special issue of Journal of Abnor-    executed psychosocial intervention may be
mal Child Psychology for December 2000 (V. 28, no.       able to maintain a child if medication (dis-
6) and of the Journal of the American Academy of Chil-   cussed below) is not desirable. Further,
dren and Adolescent Psychiatry for February 2001
(Vol. 40, no. 2), which includes several updates and
                                                         chances that a child would improve were in-
reports from this project. We note initial findings      creased with the addition of psychosocial
from that landmark effort as relevant herein.            treatment (Swanson et al., 2001) to medicine
           26 • INTERVENTIONS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER                      185

alone. Also, there is limited evidence for orga-    4. Systematic implementation of appropriate
nizational strategies being helpful with               disciplinary strategies such as time-out,
inattention/disorganization symptoms, as dis-          loss of privilege, and so on when the child’s
cussed under school interventions later, and           misbehavior cannot be safely ignored. Skills
these deserve a trial in most cases. Finally,          for effectively implementing such conse-
there is substantial evidence that behavioral          quences as time-out are also taught.
parent interventions can improve the ubiqui-        5. The contingency management skills neces-
tous oppositional/disruptive behavior of               sary to handle misbehavior are taught.
youngsters with ADHD, if not the core ADHD             These latter skills entail clear and frequent
symptoms themselves. Behavioral interven-              feedback to the child about his or her be-
tions also increase the success rate of medica-        havior, sometimes taking the form of point
tion alone in relation to critical ancillary           or token systems. With young children, the
problems such as peer relations, internalizing         points may be recorded on a chart on the re-
symptoms, and academic progress. Moreover,             frigerator. With adolescents, in contrast,
in anxious ADHD children, psychosocial inter-          point systems are unlikely to be appropriate
ventions yield equivalent outcomes to medica-          and several modifications of the program
tion alone (MTA Cooperative Work Group,                are in order, including more active inclu-
1999a, 1999b). Furthermore, psychosocial in-           sion of the teen in shaping the program and
terventions tend to enable a lower dosage of           in negotiating with parents around those
medication to be effective (MTA Cooperative            problems that are negotiable (Robin, 1998).
Work Group, 1999a). We emphasize parent
training programs in this section.                     Such child management skills exceed the
                                                    communication enhancements taught in typi-
                                                    cal parenting books and classes and are rarely
Parent Training for Behavior Management
                                                    in the repertoire of even the most sophisti-
The essential components of such programs           cated and dedicated parent. Yet, careful work
(Barkley, 1997; Forehand & McMahon, 1981)           using one of the well-manualized programs to
include the following:                              reduce oppositional and aggressive behaviors
                                                    is one of the most clearly effective interven-
1. Parents are taught to interrupt the pattern      tions in mental health services. Thus, individ-
   of coercive (aggressive) interchange be-         ual or group work on behavioral parent-child
   tween parent and child that is described by      guidance is almost always called for with
   Patterson (e.g., Patterson & Capaldi, 1991).     these children. Counselors who will be con-
   In these interchanges, the child escalates,      ducting front-line treatment of ADHD are ex-
   while parents also escalate their threats, but   horted to obtain necessary training to enable
   consequences only follow some of the time.       them to effectively implement one of the man-
   Parents are taught a three-step process in       ualized, empirically supported treatment
   which they issue a command or request,           programs in this genre. These include the
   wait one minute while ignoring misbehav-         classic programs outlined by Forehand and
   ior, remind with a warning, wait and ignore      McMahon (1981), as well as the user-friendly
   once more, and then impose a predeter-           and widely disseminated modification of
   mined consequence.                               those basic programs proffered by Barkley
2. Systematic implementation of positive            (1997, 1998) and colleagues. These manuals
   parent-child interactions that are noncon-       provide detailed materials, including hand-
   tingent, which strengthens the parent-           outs and week-by-week curricula, for system-
   child bond.                                      atic parent training. In the most cost-limited
3. Teaching the parent to praise (rather than       form of this intervention, the counselor may
   ignore) appropriate behaviors, while as          meet with the parents weekly for a period of
   often as possible ignoring (rather than at-      6 to 12 weeks to teach such a system, then
   tending to) misbehavior.                         institute periodic booster sessions over the
186     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

subsequent year to help the parents maintain         interventions, at a fraction of the effort and
the gains they have made.                            cost; this is a crucial advantage in situations
                                                     where behavioral interventions are not well
                                                     supported by insurance or are not available at
Ancillary Family Counseling                          all. For some parents, the possibility of med-
In the case of young children, preschool or          ical treatment for their child thus is looked to
early school years, such parent training may be      as the last hope in an overwhelming situation,
sufficient to improve the situation. However, it     or as a “silver bullet” for difficult and compli-
is sometimes advisable to combine this work          cated psychosocial problems. For others, med-
with counseling concerning the disability it-        ications symbolize an unwarranted effort to
self as well as other interventions that are         control their child.
underway (including medications, as we elabo-            As a result, counselors are often in an im-
rate further in the next section). This is espe-     portant position to help parents consider
cially true as children get older. Parent            their concerns, values, and feelings about the
attributions and demoralization concerning           option of medication in the treatment of their
their own role with the hyperactive child            child, and to educate parents about the role of
can be a major issue to be addressed with par-       the different components of multimodal treat-
ent education and even family counseling.            ment. Children, also, can have complex feel-
Parental disengagement, depression, lack of          ings about the prospect of medication. These
monitoring (especially with adolescent chil-         can include relief, fear of stigmatization, mis-
dren), and consequent inconsistent response          understanding medication as “taking drugs,”
to child misbehavior are among the strongest         and unrealistic attributions. As a result, simi-
correlates of poor child outcomes (Patterson &       lar discussions with children are often war-
Capaldi, 1991). Thus, in supplementing the be-       ranted, and discussion with both parents and
havioral parent training, it is of value for coun-   the child are vital in creating a positive plan
selors to educate parents about the nature of        and shared alliance for approaching the
ADHD, the normal need for additional parent          child’s behavioral difficulties. These discus-
skill building with this disorder, and the long-     sions will likely need to address cognitive re-
term value of maintaining their engagement           structuring of attributions about both the
with the child’s problems. Thus, motivating          medication itself and the nature of the child’s
parents can also be of value in that one of the      difficulties (Robin, 1998) to reduce blame and
strongest predictors of successful treatment,        self-stigmatization.
medication or otherwise, is consistent atten-
dance at physician and counselor sessions            Basic Medication Facts
(MTA Cooperative Work Group, 1999b).
                                                     The prescribing of medication falls in the
                                                     purview of the child’s physician, who may be a
                                                     primary care pediatrician or a psychiatrist. It is
COUNSELING AND PHARMACOLOGICAL
                                                     useful for the counselor to be aware of the med-
INTERVENTION FOR THE CHILD
                                                     ications commonly used and salient issues that
                                                     can occur with their use. Because they are the
The Counseling Context
                                                     most often effective and have the fewest side ef-
Few topics evoke such strong feelings in par-        fects (Elia, 1993; Rappley, 1997), the most com-
ents as the prospect of having their child           mon medications used in the treatment of
placed on psychoactive medications. Yet, the         ADHD are the stimulants: methylphenidate
impressive effectiveness of stimulant medica-        and products related to dextroamphetamine.
tions (MTA Cooperative Work Group, 1999a)            They stimulate catecholamine activity in the
mandates their consideration in a large per-         central nervous system, enhancing attentional
centage of cases with impairing ADHD symp-           focus and behavioral control in children and
toms. Medication achieves the same reduction         adults. They effectively improve behavioral
of ADHD symptoms as ambitious behavioral             problems in 70% to 90% of children who take
            26 • INTERVENTIONS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER                         187

them (Barkley, 1998). Children who fail to re-        definition helps clarify whether the interven-
spond to the first stimulant will sometimes           tion has been effective. Standardized rating
respond to the second. However, other stimu-          scales (see Conners, 1997; Hinshaw & Nigg,
lants, such as magnesium pemoline, are used           1999) can be useful in this regard. It is valuable
rarely due to more severe side effects. Other         to explain the baseline behavioral problems for
psychotropic medications might be used, such          the child, because behaviors initially reported
as tricyclic antidepressants, selective serotonin     as baseline problems are often later reported
reuptake inhibitors and buproprion, and atypi-        as side effects of the medication in placebo
cal antispychotics, but with the exception of         trials. Finally, medications are usually not uti-
buproprion, these are generally used to ad-           lized to maximum effectiveness (MTA Cooper-
dress comorbid problems such as a mood disor-         ative Work Group, 1999a). Effectiveness can be
der or Obsessive-Compulsive Disorder.                 improved by a systematic double-blind trial of
   Stimulants are short-acting. Effects on be-        medication. Teachers and parents can com-
havior are apparent within 30 to 60 minutes           plete a short Conners (1997) rating scale daily
and have worn off within three to six hours de-       for one to two weeks to provide data to deter-
pending on the nature of the preparation and          mine the child’s optimal medication and
the individual child’s reaction. They are thus        dosage (MTA Cooperative Work Group, 1999a).
given two to four times per day. Often, exact
timing and amount of dosage must be adjusted
to achieve the best effect. Monitoring of med-
                                                      SCHOOL INTERVENTIONS
ication use involves office visits at least every
three to four months with review of height,
                                                      Background
weight, blood pressure, pulse, side effects, and
effectiveness of the medication. Common side          School intervention is generally advised in
effects include stomachache, headache, ap-            cases of ADHD for several reasons. Interven-
petite suppression, and sleep disturbance;            tions with parents tend to yield larger results
these often subside in a short time, but persis-      at home than at school. Additionally, although
tent appetite suppression may need to be ad-          medications are the most effective at reducing
dressed with modified eating regimes to               off-task behavior and improving compliance in
assure adequate weight gain. Less common but          school, they are not sufficient alone to ensure
notable side effects are dysphoric mood and           appropriate socialization and learning. As re-
stereotyped or tic-like behaviors. Although           viewed in detail by Pfiffner (1996) and Pfiffner
the side effects are similar with the two major       and Barkley (1998), the school context for
types of stimulants, some children will have          ADHD children has changed dramatically in
fewer problems with one than the other                the past decade, with recognition by the U.S.
(Barkley, 1998). Secondary sleep problems can         Department of Education in 1991 that ADHD
usually be corrected by adjusting the timing of       could be considered a disabling condition and
the dose. “Rebound” is a concern of some par-         qualify children for special education services
ents. It refers to some children’s irritable or la-   under Section 504 of the Rehabilitation Act
bile mood as the medication is wearing off,           (Davila, Williams, & MacDonald, 1991). This
often in the late afternoon. The physician can        recognition has been accompanied by numer-
usually address the problem by tapering the           ous developments in service modules that can
dose. For more detailed information, readers          be used with ADHD in the school. Thus, if a
may consult Barkley (1998) or Elia (1993).            Section 504 or special education evaluation has
                                                      not been initiated for the child within the past
                                                      three years, one of the counselor’s first actions
Additional Counseling Issues
                                                      will be to ensure that such an evaluation is
The counselor may also assist the family with         begun (in most states, these can be compelled
defining the target behaviors and the base-           by parent written demand). For the counselor,
line severity of the problem prior to initiating      a primary concern will then be assisting
treatment, particularly with medications. Such        school personnel to recognize the intervention
188     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

options available, advising parents on the          Other School Strategies
range of options the school may be able to con-
                                                    Under the purview of counseling to assist with
sider, and at times, providing technical assis-
                                                    organizational strategies, additional interven-
tance to school personnel in implementing
                                                    tions often warrant consideration. One domain
their program. The key elements of an optimal
                                                    entails further counseling of the children or
school program include the following: (1) a
                                                    teens regarding ADHD and their self-
school-based behavioral program that delivers
                                                    conception and attributions around the inter-
consequences within the school setting; (2) or-
                                                    vention being offered to them. A second key
ganizational strategies in the classroom ( Jones,
                                                    area involves “coaching” or case management
1994); and (3) peer interventions. We focus on
                                                    services to support the school program, thus
behavioral interventions here because these
                                                    helping children to track their assignments
are most likely to engage the counselor in col-
                                                    and responsibilities. Organizational strategies
laboration with school personnel.
                                                    may include an “in” and “out” folder at home
                                                    and school for completed and to-be-done as-
Behavioral Intervention at School                   signments, a to-do list of assignment tasks for
                                                    the next hour or for the day, different colored
The logic of behavioral interventions in the
                                                    materials and worksheets to help focus atten-
school setting is very similar to that in the
                                                    tion, and modified work settings to minimize
home setting. The teacher faces the task of
                                                    distracting stimulation. For example, some
providing clear behavioral expectations, con-
                                                    children are able to successfully complete an
sistent praise for on-task behavior (resisting
                                                    exam in the hallway, but not in the classroom.
the tendency to ignore on-task behavior),
                                                    Detailed suggestions on working with school
and either ignoring or implementing conse-
                                                    settings are provided by Pfiffner (1996), Jones
quences for off-task or disruptive behavior.
                                                    (1994), and Swanson (1992). The counselor can
Depending on the age of the child, this pro-
                                                    make these options known to parents and
gram can be accompanied by a point system
                                                    school personnel, and in some instances can
to enable children to monitor their progress
                                                    serve as the coach to help the child implement
toward their behavioral goal. Problems with
                                                    strategies and troubleshoot any problems with
implementing such programs in the school
                                                    particular strategies that are being tried.
can include: (1) teacher lacks the skills or
knowledge to carry out the intervention effec-
tively; (2) teacher lacks time or energy to         INTEGRATING THE INTERVENTION TEAM
carry out the intervention; or (3) teacher ob-
jects on philosophical grounds to the behav-        As is apparent from the preceding, the coun-
ioral intervention. In the first instance, the      selor attempting to coordinate treatment for
counselor may need to assist the teacher in lo-     an ADHD child will need to be in contact with
cating the appropriate support services to es-      the school, the physician, and potentially a
tablish a behavioral program. In the second         consulting psychologist as well as the parents
instance, provision of an in-class behavioral       and the child. Extensive collateral contact will
aide is advisable; advocacy may be needed to        thus be essential to successful coordinated in-
push the school to do so. In the final instance,    tervention. For example, the physician may be
if an understanding cannot be reached, par-         unaware of some of the comorbid conditions
ents may need to be counseled to seek a dif-        the counselor has noted, or may assume coun-
ferent teacher, classroom, or school where          seling is addressing particular issues. If all
appropriate intervention can be delivered.          parties are in agreement, it can be prudent in
Notably, the situation is more difficult with       mild to moderate cases to initiate behavioral
adolescents; multiple teachers may be in-           interventions for a period of several months
volved and their coordination may be quite          and evaluate progress prior to determining the
difficult depending on the resources of the         necessity for pharmacological intervention.
local middle or high school.                        However, in cases of severe impairment or
           26 • INTERVENTIONS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER                               189

limited resources, the press for immediate          reading, then the long-term prognosis for chil-
medication management may of necessity win          dren with ADHD is often quite good. Skilled
out. Coordination of behavioral programming         counselors can help to ensure that the children
across home and school is vital, as is active ed-   in their care are among those with the positive
ucation of parents and teachers to the reality      outcomes.
that medication alone will not assure an opti-
mal outcome for the child. The counselor may        References
play a crucial role in communicating with both
teachers and parents regarding the principles       American Psychiatric Association. (1994). Diagnos-
and goals of the behavioral management pro-              tic and statistical manual of mental disorders (4th
                                                         ed.). Washington, DC: Author.
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                                                    Barkley, R.A. (1997). Defiant children: A clinician’s
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                                                    Conners, C.K. (1997). Conners Rating Scales–Revised.
                                                         Toronto: Multi-Health Systems.
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                                                         of children with attention deficit hyperactivity dis-
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                                                         (1990). Long-term criminal outcomes of hyper-
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                                                         activity–impulsivety: Attention deficit and
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                                                         Principal diagnosis and place of visit. National
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                                                         tics, 13, 137.
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Hinshaw, S.P., & Nigg, J.T. (1999). Behavior rating          Pfiffner, L.J. (1996). All about ADHD: The complete
     scales in the assessment of disruptive behav-                practical guide for classroom teachers. New York:
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     Lucas, & J. Richters (Eds.), Diagnostic assess-         Pfiffner, L.J., & Barkley, R.A. (1998). Treat ment of
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     American Psychological Association.
      27          BULLYING
                  Counseling Perpetrators and Victims


                  Richard J. Hazler




DEFINING THE PROBLEM                                       damage for victims is seen in social, academic,
                                                           and emotional difficulties as well as the poten-
The emerging body of knowledge on repeti-                  tial for suicide or violent aggression against
tive peer-on-peer abuse in the form of bully-              others. Immediate effects for those who bully
ing has made it clear that the problem can                 frequently generally relate to disciplinary ac-
have deadly consequences in acts of revenge                tions, social difficulties, and potentially be-
against others (Hazler & Carney, 2000), is re-             coming targets of revenge. Long-term damage
lated to suicidal thinking (Carney, 2000), and             can be seen in adulthood, when bullies are
can influence suicidal acts (Morita, Soeda,                more likely to have criminal records and vic-
Soeda, & Mitsuru, 1999). These forms of peer-              tims can suffer social and emotional disabili-
on-peer abuse can be recognized in every                   ties. The damage also extends to bystanders,
counselor’s practice because the vast majority             who, recognizing this form of peer-on-peer
of people have been either an abuser, victim,              abuse as a potential threat to themselves, per-
or bystander to these forms of abuse that                  ceive a climate of anxiety and fear over which
occur in all parts of our society (Hazler, 1998)           they have little control. The scope of the prob-
and are international in scope (Smith, Mad-                lem then extends far beyond individual acts of
sen, & Moody, 1999).                                       youth to the immediate climate in schools, fam-
   There is an internationally agreed on defini-           ilies, communities, and eventually to adult de-
tion for bullying situations that emphasizes               velopment and overall social conditions.
three key factors. This definition gives coun-
selors direction in evaluating the degree of
                                                           KEYS TO UNDERSTANDING THE PROBLEM
concern and in developing treatment plans:
“Bullying is the repeated (not just once) harming
                                                           Developmental Component
of another through words, social actions or
physical attack. The act of bullying is unfair be-         Harassment and abuse among youth was once
cause the bully is either physically stronger or           thought to be “child’s play,” as studies utiliz-
more verbally or socially skilled than the vic-            ing adult estimates of such problems and their
tim(s). An individual ( bullying) or group                 impact on youth suggested that the incidence
(mobbing) may carry these actions out” (Ha-                was low, with minimal problems emerging
zler, Miller, Carney, & Green, in press). These            from them. Very different results surfaced
repetitions of what may appear to be mini-                 when the same problems were studied from
mally hurtful separate actions when individu-              the students’ point of view. The vast majority
als do not have a fair chance of defending                 of high school students (88%) report having
themselves combine to create conditions that               seen harassment and bullying by other stu-
can produce immediate and long-term damage                 dents for extended periods of time during
for both the bullies and the victims. Immediate            their school careers, and 90% of those students

                                                     191
192     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

believe the bullying caused significant social,     ing of abuse that falls clearly outside of so-
emotional, or academic problems for the vic-        cially acceptable limits as students approach
tims (Hazler, Hoover, & Oliver, 1991). A link       middle school along with an increase of behav-
between bullying and suicide was later sup-         iors that cause harm while not receiving recog-
ported by identifying the characteristics of        nition or punishment from adults or peers
hopelessness, helplessness, isolation, and low      (Smith, Madsen, & Moody, 1999). People learn
self-esteem as key risk factors for both prob-      through social experiences how to avoid being
lems (Carney, 2000). This type of information       seen hurting another and how to dominate in
gained more public attention as the mass            ways that others will have trouble classifying
shootings in schools of the late 1990s and early    as problem behaviors. These are the same age
2000s highlighted the fact that many of these       levels at which students report the highest lev-
same personal characteristics were recogniza-       els of bullying and harassment. Peers and
ble in the young killers.                           adults alike have more difficulty distinguish-
   The current widely accepted theory recog-        ing play from abuse at these stages, and there-
nizes that serious youth violence develops          fore the problem situations can continue as
from behaviors that have tended to give adults      low-level repeated abuse (Hazler et al., in
less concern, such as teasing, trash talking, and   press; Schafer & Smith, 1996).
bullying at the lower end of the violence con-
tinuum. Actions such as antisocial behavior,
                                                    Individual and Environmental Characteristics
murder, and suicide at the upper end of this
continuum do make headlines, but it is at the       There are individual characteristics that
lower end of the continuum where the ability        appear to influence the potential for develop-
to intervene in the development of these prob-      ment and continuation of bullying and ha-
lems is most effective.                             rassment. Certainly, someone with less
   Dominance aggression is generally consid-        intellectual, emotional, social, or physical abil-
ered to be the form of aggression that is most      ity is at a disadvantage compared to another
likely to move confrontations that begin as ver-    who has more of these qualities. These inher-
bal sparring to more serious social and physi-      ent advantages or disadvantages that change as
cal behaviors (Weisfeld, 1994). The goal in         children grow and mature will cause youth to
dominance aggression is to overpower and            experiment with being in powerful or power-
control the other person in one way or another,     less positions, but importantly, it takes more
thereby confirming one’s own power, influ-          than these initial differences for bullying or
ence, and self-worth. Neither participant           victimization to continue. Individual charac-
wants to be in the dominated position with the      teristics, developmental factors, and environ-
accompanying loser feelings, so each tries to       mental conditions also play critical roles.
overpower the other, thus continuously raising         A worldwide study of experts on the sub-
the personal stakes. What starts out as verbal      ject found agreement on several characteris-
or physical dominance play can often turn into      tics of bullies and victims that appear to be
threats and disputes about reputation and so-       molded not by heredity, but by developing
cial identity that have a much greater impact       personality traits and learned behaviors (Ha-
on people than anyone planned.                      zler, Carney, Green, Powell, & Jolly, 1997).
   Dominance aggression can first be seen at        These experts agreed that those who are reg-
about the age of 3, when children become moti-      ular bullies are more aggressive, are easier to
vated to take a toy from another child more for     anger, are poor interpreters of the actions of
the demonstration of power over that individ-       others, and demonstrate a lack of empathy for
ual than actually having the toy. As intellec-      others. These are people smashing their way
tual, verbal, and social skills develop with age,   through relationships to get what they want,
the initially physical forms of dominance give      paying little attention to their role in their
way to a more diverse variety of socially toler-    victim’s situation or pain. By contrast, the ex-
ated behaviors to exert power and control over      perts viewed victims as overaccepting of their
others (Weisfeld, 1994). The result is a lessen-    own weaknesses and operating on feelings of
                                                                           27 • BULLYING         193

poor self-concept, inadequacy, and self-blame.      that influences how they relate to themselves
Whereas bullies might need to be punished to        and others throughout their life. In relation to
help them see their wrongs, victims appear to       prevention and intervention efforts, the char-
punish themselves for their self-perceived          acteristics of abusive situations and the pain
weaknesses.                                         they cause may be best generalized into the
   The environments of bullies and victims          categories of isolation, dehumanization, and
also appear different in ways that would im-        inevitability (Hazler & Carney, 2000).
pact both problem development and interven-             Isolation is required for abuse of another to
tion. Bullies tend to be in homes where there is    continue over time. Bullies cannot continue to
less time spent as a family unit, more family       abuse when others effectively step in to control
problems, and inconsistent discipline. To-          the situation, support the victim, and discredit
gether, these factors may put the young person      the bully. Sometimes, this takes the form
in a position where a less than supportive          of the bully manipulating a situation so that a
model is presented and one that promotes a          person is physically alone; at other times, it is
more random learning of social interaction          the creation of an atmosphere where others
from peers and outsiders rather than a consis-      will not step in to help the victim or confront
tent family. Victims, on the other hand, have a     the abuser. In either case, victims have the ten-
tendency to come from more protective and           dency to play into the abuser’s hands by seek-
enmeshed home environments where an over-           ing isolation to avoid more humiliation or
abundance of time is consistently spent in the      greater danger rather than making their in-
home or as a family unit. In this case, the child   ability to handle the situation more public,
may not have sufficient opportunity to develop      where support is available.
critical independence skills necessary to nego-         Dehumanization is related to an abuser’s
tiate the more variable nonfamily situations.       lack of empathy and the victim’s sense of un-
These influences are often reinforced outside       acceptability. Name calling is the most com-
the home when adult and peer bystanders do          monly seen application of dehumanization. It
not intervene to stop bullies from inappropri-      is not unique to bullying, but is quite common,
ately abusing victims who can then become so-       as when citizens of a country give hurtful and
cial pariahs, as bystanders seek to avoid           impersonal nicknames to the enemy when
connections with victims for fear of becoming       they go to war. The same thing happens in vir-
the bully’s next target.                            tually any conflict when the individuals or
   The combination of dominance aggression,         groups do not want to recognize the humanity
inherent individual characteristics, learned        of and personal commonalties with their ri-
behaviors, and environmental influences ap-         vals. By implementing a derogatory label, bul-
pear to provide strong support for why virtu-       lies effectively dehumanize their victims,
ally all youth report contact with bullying         thereby reducing any rationale for treating
and harassment. The majority of these inci-         them as living, breathing, feeling persons like
dents appear to be brief time periods where         themselves. The impact of this dehumaniza-
productive social learning takes place, result-     tion is to reduce the responsibility for human
ing in little to no therapeutic intervention        caring in the bully and others while also pro-
being needed. Unfortunately, social learning        moting a sense of inadequacy and unaccept-
does not always work effectively or in a            ability in the victim.
timely manner, and some youth suffer serious            A sense of inevitability emerges in
consequences.                                       victims, bystanders, and bullies as more at-
                                                    tempts to change the situation fail. For bul-
                                                    lies, this inevitability promotes continuation,
Situational Characteristics and Their Impact
                                                    as confidence that an action will lead to the
It remains unclear exactly why one young per-       desired result is confirmed. Victim feelings
son may react to abuse with violence while an-      of being less than human and increasingly
other submissively internalizes the pain. What      isolated from others become more and more
is known is that all victims experience pain        difficult to fight as the sense grows that
194     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

there are no socially acceptable ways to im-          and a major factor in the development of
prove the situation. Similar feelings of help-        problematic outcomes.
lessness in victims’ inability to make a            • Reducing physical, social, and/or emo-
difference in negative situations also carry          tional isolation are primary goals that in-
over to bystanders. The developing feelings of        crease support for victims, highlight the
helplessness, hopelessness, and worthlessness         social unacceptability of bullies, and en-
leave youth believing that they have few op-          courage the productive involvement of by-
tions beyond dropping out in one way or an-           standers.
other. People who see their situation and pain      • The fact that continuation of a bullying re-
as inevitable feel that they have little to lose      lationship requires consistent patterns of
when considering leaving the system, cutting          interactions among bullies, victims, and
emotional ties to others, or attempting to end        bystanders emphasizes the need for chang-
a life (McDowell & Stillion, 1994). This sense        ing any small piece of the pattern. Inter-
of inevitability becomes a primary concern, as        ventions are directed at breaking the cycle
it signifies the point in the victim’s process        of bullying by disrupting these unhealthy
where extreme lashing out at self or others           patterns.
may become seen as the only option.

                                                    Environmental Interventions

COUNSELING EMPHASES                                 The most natural forms of prevention and in-
                                                    tervention with bullying behavior are related
The previous findings point professionals to        to the social learning that takes place, not in a
some commonly accepted directions in the            counselor’s office, but in the young person’s
counseling of bullies, victims, and by-             real-life social environment. Most bullying
standers, who are also impacted by the situa-       prevention and intervention programs are
tions. The overall focus of interventions can       founded on efforts to create an environment
be generally summarized as follows:                 that teaches and supports desired behaviors
                                                    and discourages inappropriate social behav-
• Most bullying is a transient developmental        iors such as bullying. The starting place is to
  occurrence as youth experiment with newly         produce an environment in a school, treat-
  recognized ways to exercise power over oth-       ment facility, home, or other form of commu-
  ers ( bullying) or as they experience a loss of   nity with the following key characteristics:
  control to others (victimization). The com-
  mon developmental nature of these prob-           • Establishes clear policies and promotes di-
  lems emphasizes the need to provide                 rect actions that stop verbal, social, and
  prevention efforts for everyone first. Mini-        physical abuse when it occurs.
  mally intrusive interventions are appropri-       • Brings widely held member experiences,
  ate for the vast majority of transient              observations, and beliefs into the open.
  bullying situations; the most intense disci-      • Provides community members with the
  plinary and therapeutic measures are re-            knowledge and skills needed to under-
  served for those bullying behaviors that            stand the impact of their own behaviors
  continue over time.                                 and to react effectively to the problem be-
• The highly relational nature of bullying            haviors of others.
  gives emphasis to promoting skills, realis-
  tic consequences, and reinforcements                 A sound structure for an environment that
  that focus on social learning and social          will reduce bullying and its effects begins
  development.                                      with policies and responsibilities that are logi-
• Empathy-generating techniques are em-             cal, are based on local culture, have wide-
  phasized because dehumanization is con-           spread public awareness and support, and are
  sistent in the implementation of bullying         implemented consistently. Youth, parents,
                                                                           27 • BULLYING         195

teachers, and others need to be involved in the     they relate to the social arena, is a basic tenet
development, implementation, and regular            of treatment.
reevaluation of policies and procedures for re-        Counseling and other techniques that en-
acting to abusive situations. Consensus must        courage the development of empathy for vic-
be developed as to what constitutes verbal, so-     tims and others are key to successful work
cial, or physical abuse, the means of dealing       with bullies (Garrity, Jens, Porter, Sager, &
with it, and the understanding that everyone        Short-Camille, 1996; Hazler, 1996). These ef-
has a distinct role in recognizing and stopping     forts focus on the dehumanizing techniques
it on an ongoing basis. This foundation allows      of bullies. The more abusers recognize the
much of the critical social learning to be imple-   hurt of their victims in a personalized way,
mented naturally through a supportive envi-         the more difficult it becomes for them to con-
ronment.                                            tinue causing them pain. Techniques such as
                                                    reverse role-play, imaging another’s world,
                                                    bibliocounseling, and other methods that get
Bully-Specific Interventions
                                                    abusers in touch with the lives and pain of
Characteristics of those who are found to be        others are used to promote a more human-
consistent bullies are focused around physical      ized picture of others.
and verbal aggressiveness, anger, poor inter-          Teaching problem solving, anger manage-
pretation of the actions of others, and a lack of   ment, conflict resolution, and social skills is
empathy toward others (Hazler et al., in press;     often an essential part of the treatment for
Hunt, 1993). The addition of a problematic          abusers, who generally have problems in
home environment supports the bully who is          these areas. Selecting means and places for
more likely to seek self-serving forms of grati-    abusers to practice these skills with initially
fication than more socially acceptable options.     low levels of risk is just as important as the
Techniques for dealing with these problems          use of the skills. One example of a commonly
then logically emphasize consistency of conse-      effective environment is to have older stu-
quences for inappropriate actions, gaining em-      dents work in supportive roles with much
pathy for others, and developing skills in          younger children. The advantage in such an
anger management, problem solving, and con-         environment is that the much younger child is
flict resolution.                                   not threatening to the skills and abilities of
    Having negative consequences for aggres-        the older student. This lack of threat from the
sive acts is always a foundation of the treat-      younger child reduces the need to demon-
ment for bullies. The more reality-based and        strate dominance and allows for the practice
socially appropriate the consequences, the          of positive social skills with the resulting sup-
better they serve as social learning tools. The     portive feedback.
more consistently both adults and peers can            Family work for bullies often revolves
implement these at school, at home, and in the      around increasing understanding, closeness,
community, the better.                              and consistency of family involvement (Oliver,
    Treatment of childhood bullies recognizes       Oaks, & Hoover, 1994). Encouraging more per-
the developmental nature of the problem as          sonal involvement among family members is at
different from simple aggressiveness, Opposi-       the core of treatment. This may be as simple as
tional Defiant Disorder, or Conduct Disorder,       eating together more often, setting aside fam-
although these and other diagnosable condi-         ily time, discussing the school day, or review-
tions may exist concurrently with bullying.         ing homework regularly.
Bullying behaviors primarily emanate from
developmental and situational problems re-
                                                    Victim-Specific Interventions
lated to social learning. Therefore, counseling
these youth to identify and deal more produc-       Techniques for dealing with victims revolve
tively with their individual needs, personal        around their often common characteristics, in-
difficulties, and lack of skills, particularly as   cluding feelings of inadequacy, self-blame,
196     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

poor self-concept, and being incapable, which       is helpful when it increases victims’ ability to
are reflected in victims’ overacceptance of         see abusers and bystanders in a more realistic
their own weaknesses (Hazler et al., in press;      light, to identify issues they have in common,
Smith, 1991). Relationships with peers, adults,     and to then seek actions that can utilize these
and even an overinvolved family can serve to        factors to improve the situation.
reinforce such feelings. These individuals             Once a more accurate picture of self, oth-
often have much more potential to deal with         ers, and situation is gained, counselors can
their victimization than they recognize. Gain-      use a number of specific therapeutic tech-
ing a more realistic picture of their situation     niques to help the victim. Some commonly
and their abusers, enlightening them to their       used techniques found to have critical value
strengths, teaching assertiveness skills, and       include the following:
providing opportunities to practice these
skills are the core emphases for individual         • Avoid giving the abusers the emotional
counseling with victims.                              payoff they are seeking. This might include
   Pain, suffering, sadness, depression, and          the victim who cries or acts sad at each in-
anger are all likely to be a part of the clinical     cident as well as the victim who consis-
presentation of a victim. The longer and more         tently becomes angry and does not turn
consistently the abuse continues, the more            that anger into effective coping actions.
contexts in which it occurs, and the more iso-      • Learn techniques for being physically and
lated the victim has become, the higher will          verbally assertive but not aggressive. Phys-
be the levels of these symptoms. Supportive           ical techniques involve posture, eye con-
counseling is therefore the starting place for        tact, and other physical mannerisms that
counseling victims. They need to know first           demonstrate confidence. Verbal skills in-
and foremost that there is an individual who          clude speaking up, using “I” statements,
can be trusted, who sees them as competent,           showing understanding, and demonstrat-
who understands their feelings and situation,         ing confidence.
and who has confidence that options can be          • Strengthen continuing friendships and
developed for a seemingly hopeless situation.         make new ones. Developing more friend-
   Developing a more accurate picture of              ships, gathering more people around more
themselves, their situation, and those involved       often, and making closer friendships all
is an early step in counseling victims because        serve to reduce isolation, increase personal
they are likely to overemphasize their per-           support, and reduce the likelihood of con-
sonal weaknesses and underemphasize their             tinued bullying.
strengths. The counseling focus is to assist        • Seek support when necessary. Determin-
victims in developing a more accurate picture         ing when, where, how, and from whom to
of their abilities and how they relate to what is     seek support is often a lesson needed for
happening in problem situations.                      victims.
   Having victims develop a more realistic          • Encourage family activities that foster in-
perspective of their abusers can often be as          dependence in addition to the support that
important to counseling as improving their            some overinvolved families provide. Youth
own self-perceptions. Victims as well as by-          need to develop skills and confidence in
standers who have experienced dehumaniz-              their independence beyond their family
ing actions of bullies often lose a sense of          unit.
empathy for the abusers. This reduced ability       • Consider doing the unexpected. Continual
to accurately picture the human side of their         abusers are not looking for a fair contest,
tormentors and those who stand by without             nor are they looking for surprises. They are
acting reduces victims’ ability to determine          seeking consistency in the reactions of
actions to effectively deal with abusive situa-       their victims. Victims who begin to act in
tions and increases the potential in victims          less predictable ways create situations that
for thoughts or acts of vengeance. Counseling         are not conducive to continual bullying.
                                                                           27 • BULLYING         197

• Practice necessary behaviors. Good ideas do       This is not the time to settle issues between
  not turn into productive actions automati-        participants. It is the time to reduce tension,
  cally. Counseling needs to provide oppor-         give recognition to the seriousness of the situ-
  tunities to practice new behaviors through        ation, follow through with the formal behav-
  imagery techniques and role play and also         ioral rules or laws relating to the situation,
  by identifying real-life situations where the     and assure all participants that more will be
  actions can be practiced with a maximum           done about the situation when things have
  chance of success and a minimal chance of         calmed.
  failure. Most of the necessary behaviors to          Evaluation is focused around individual dis-
  be learned are useful in many life situa-         cussions with bullies first and then victims, in
  tions, so that they can be practiced in safer     that order whenever possible. Seeing the
  situations in preparation for implementing        abuser first is a common technique that re-
  them in bullying situations.                      duces the potential of the abuser’s blaming the
                                                    victim for being a “tattletale.” The primary
                                                    need for individuals at this stage is to be heard
Joint Bully and Victim Interventions
                                                    and understood in relation to the situation and
Bullying and its resulting victimization are        to other aspects of their life that may be influ-
best defined as problem relationships, in that      encing their actions. This is not a time for
they could not persist without a continuing         judging right from wrong, which should be oc-
relationship between bully and victim. Be-          curring separately with those adults who deal
cause the relationship is by definition an un-      with disciplinary matters. The counselor is
balanced one, intervention techniques either        looking to develop positive relationships with
seek to reduce the occurrence of the relation-      anyone involved, to understand individual
ship so that one person does not continue to        needs, problems, and viewpoints, and to look
get hurt or to infuse balance by changing the       for areas of potential common concern among
individuals. Only when better balance can be        participants. Examples of these areas of com-
assured should attempts be made to work             mon concern may include things as simple as
jointly with bully and victim.                      participants wanting to avoid being in more
   Promoting Issues in Common (PIC) is a            trouble or as complex as wanting to be more ac-
general model for dealing with continuing           cepted. If such commonalities are not found,
abusive relationships that reflects the basic       there will be little hope for joint meetings, but
tenets of when and how to bring bullies and         as areas of commonality are discovered, they
victims together for joint interventions            become the focus of potential joint meetings.
(Hazler, 1996). Three basic stages of PIC em-          Active interventions begin with individual
phasize gaining control of the situation, then      care and strengthening of each participant.
evaluating the problem and potential for            Only if and when common goals are uncov-
joint efforts, and finally using active joint in-   ered and there is sufficient strength in each
terventions where and when appropriate.             participant to assure a balanced interaction
Emphasized throughout is the need for giv-          should joint meetings be planned. The over-
ing direct attention to bully, victim, and by-      riding goals for any joint meeting among a
stander needs and only bringing individuals         bully, a victim, and, potentially, bystanders
together for joint work when the situation as-      are to demonstrate equality of participants
sures a significant degree of success.              and produce progress, no matter how small.
   The gaining control stage emphasizes the ini-    Early meetings in particular, then, should be
tial need to reduce danger in the situation and     highly structured and focused on specific is-
to act whenever abuse seems to be occurring.        sues that have been previously agreed on in-
Interventions should be as minimally intru-         dividually with the counselor. It is the future
sive as possible while still reducing the danger    of the relationship and how to meet these
to minimize negative repercussions and im-          joint goals that provide the framework, not
prove the chances for joint relationships later.    placing blame for the past.
198      PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

    What should emerge from joint meetings                 Hazler, R.J., & Carney, J.V. (2000). When victims
are agreed on actions that are specific enough                 turn aggressors: Factors in the development
to be clearly observed and limited enough to                   of deadly school violence. Professional School
create a high possibility for success. General                 Counseling, 4, 105 –112.
agreements such as “We’ll do better” provide               Hazler, R.J., Carney, J.V., Green, S., Powell, R., &
                                                               Jolly, L.S. (1997). Areas of expert agreement
little therapeutic value, whereas more specific
                                                               on identification of school bullies and vic-
agreements, such as “We will only call each
                                                               tims. School Psychology International, 18, 3 –12.
other by our actual first names and will stay              Hazler, R.J., Hoover, J.H., & Oliver, R.L. (1991).
out of each other’s way between classes,” pro-                 Student perceptions of victimization by bul-
vide much greater opportunity for both appli-                  lies in schools. Journal of Humanistic Education
cation and evaluation. Subsequent meetings                     and Development, 29, 143 –150.
focus first on evaluating the degree of success            Hazler, R.J., Miller, D., Carney, J.V., & Green, S. (in
of carrying out agreements, altering agree-                    press). Adult recognition of school bullying
ments to make them more workable, and, as                      situations. Educational Research.
the situation improves, looking for broader                Hunt, R.D. (1993). Neurobiological patterns of ag-
and more generalizable agreements on relat-                    gression. Journal of Emotional and Behavioral
                                                               Problems, 2, 14 –19.
ing to each other.
                                                           McDowell, E.E., & Stillion, J.M. (1994). Suicide
    Treating bullies and victims jointly is never
                                                               across the phases of life. In G.G. Noam &
the first step and sometimes not possible for a                S. Borst (Eds.), Children, youth, and suicide: De-
long time, if at all. When it is possible, how-                velopmental perspectives (pp. 1–7). San Fran-
ever, it provides a very strong therapeutic tool               cisco: Jossey-Bass.
for the current situation and for the long-term            Morita, Y., Soeda, H., Soeda, K., & Mitsuru, T.
growth of everyone concerned. Learning to                      (1999). Japan. In P.K. Smith, Y. Morita,
effectively improve what once seemed to be                     J. Junger-Tas, D. Olweus, R. Catalano, &
insurmountable problems in a relationship                      P. Slee (Eds.), The nature of school bullying: A
teaches major life lessons about working in re-                cross-national perspective (pp. 309–323). New
lationships. These lessons build skills to deal                York: Routledge.
                                                           Oliver, R., Oaks, I.N., & Hoover, J.H. (1994). Family
with future problems and also confidence in
                                                               issues and interventions in bully and victim
individuals’ ability to overcome difficult situa-
                                                               relationships. School Counselor, 41, 199–202.
tions—if not today, then tomorrow—if suffi-                Schafer, M., & Smith, P.K. (1996). Teachers’ percep-
cient time, energy, and flexibility are included               tions of play fighting and real fighting in pri-
in the process.                                                mary school. Educational Research, 38, 173 –181.
                                                           Smith, P.K. (1991). The silent night mare: Bullying
                                                               and victimisation in school peer groups. The
References
                                                               Psychologist: Bulletin of the British Psychological
Carney, J.V. (2000). Bullied to death: Perceptions of          Society, 4, 243 –248.
    peer abuse and suicidal behavior during ado-           Smith, P.K., Madsen, K.C., & Moody, J.C. (1999).
    lescence. School Psychology International, 21,             What causes the age decline in reports of
    44 –54.                                                    being bullied at school? Towards a develop-
Garrity, C., Jens, K., Porter, W., Sager, N., & Short-         mental analysis of risks of being bullied. Edu-
    Camille, C. (1996). Bully-proofing your school:            cational Research, 41, 267–285.
    A comprehensive approach. Journal of Emotional         Weisfeld, G.E. (1994). Aggression and dominance
    and Behavioral Problems, 5, 35 –39.                        in the social world of boys. In J. Archer (Ed.),
Hazler, R.J. (1996). Breaking the cycle of violence: In-       Male violence (pp. 42–69). London: Routledge.
    terventions for bullies and victims. Washington,
    DC: Accelerated Development.
Hazler, R.J. (1998). Promoting personal invest ment
    in systemic approaches to school violence. Ed-
    ucation, 119, 222–231.
                  ASSESSMENT AND TREATMENT
                  RECOMMENDATIONS FOR
     28           CHILDREN AND ADOLESCENTS
                  WITH DEPRESSION


                  Benedict T. McWhirter and Jason J. Burrow




Until recently, depression in childhood and               ETIOLOGY OF DEPRESSION
adolescence was not well addressed in the psy-
chological literature or well delineated from             An extensive discussion of the etiology of de-
other child and adolescent difficulties. Depres-          pression is important for understanding pre-
sion was often believed to be simply a sign of            vention and treatment but is beyond the scope
other problems and behaviors associated                   of this chapter. The most common models for
with it, such as anxiety, aggressiveness, delin-          explaining the etiology of depression are bio-
quency, somatic complaints, substance use,                logical, behavioral, cognitive, psychodynamic,
poor peer relationships, poor school perfor-              and family. Biological, behavioral, and cogni-
mance, school phobia, loss of initiative, and so-         tive are the only models of depression briefly
cial withdrawal (Miller-Johnson, Lochman,                 discussed below due to space constraints. Bio-
Coie, Terry, & Hyman, 1998). Currently, ex-               logical models focus on the role of genetic
perts agree that depression in childhood and              factors or emphasize biochemical aspects of
adolescence is a substantial problem. In fact,            depression. There is a strong genetic compo-
the incidence, nature, and treatment of depres-           nent in the risk of depression (Kovacs & De-
sion during childhood and adolescence have                vlin, 1998), and it has been reported that
been topics of extensive research in recent               children of depressed parents are three times
years (e.g., Kovacs & Devlin, 1998; Lewinsohn,            more likely to have a major depressive episode
Rohde, & Seeley, 1998). Depression in youth is            at some point during their lives (Garber &
now viewed as a significant problem that af-              Robinson, 1997).
fects approximately 30% of the adolescent pop-               Behaviorists view depression as a result of
ulation and between 2% and 5% of younger                  significant loss and the consequence of inade-
children (Lewinsohn, Rohde, et al., 1998). One            quate or insufficient reinforcement (Kovacs &
in five young people report a minimum of one              Devlin, 1998). Lewinsohn’s social learning
episode of major depression by the age of 18              theory, for instance, suggests that depressive
and adolescents seen in mental health centers             behaviors are determined by the presence or
are most frequently diagnosed with an affec-              absence of reinforcers and are maintained
tive disorder. Additionally, youth who have               through the reduction of response-contingent
had depression are likely to have another epi-            reinforcing events. Depression may be the re-
sode within a few years (Kovacs & Devlin,                 sult of limited positive reinforcement for the
1998). Thus, depression is a serious problem              individual, which is determined by the num-
faced by many young people.                               ber of potentially reinforcing events, the

                                                    199
200     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

number of these events available in the envi-         Self-Report Measures
ronment, and the individual’s social skills to
                                                      Screening for current depressive symptoms in
elicit accessible reinforcers (Lewinsohn &
                                                      children and adolescents is commonly done by
Hoberman, 1985).
                                                      administering self-report measures. Some of
   Among the cognitive models of depression,
                                                      the most commonly used self-report measures
Beck and colleagues (1979) suggest that cogni-
                                                      include the Children’s Depression Inventory
tion and affect are interactive, and that the
                                                      (CDI; Kovacs, 1985a), the Beck Depression In-
prior occurrence of cognition will determine a
                                                      ventory II (BDI II; Beck, Steer, & Brown, 1996),
person’s affective response to an event. If
                                                      the Center for Epidemiologic Studies Depres-
cognitions are distorted or inaccurate, the in-
                                                      sion Scale (CES-D; Radloff, 1977), and the
dividual’s emotional response will be inap-
                                                      Children’s Depression Scale (CDS; Tischer &
propriate. Dysphoria may then be the affective
                                                      Lang, 1983). Self-report measures are used as a
response of one’s tendency to cognitively in-
                                                      quick and efficient method to screen for de-
terpret experiences as negative or self-
                                                      pressive symptoms in children and adolescents
devaluative. Seligman’s (1974) “learned
                                                      in many settings (e.g., clinic, school). These
helplessness” model contends that depression
                                                      measures are also used to identify urgent
exists in people who perceive that they have
                                                      problems such as suicide ideation and risk of
no control over their environment. They de-
                                                      self-harm and provide indicators of change
velop self-defeating attributions and make in-
                                                      during treatment (Lewinsohn, Rohde, et al.,
ternal (feeling responsible for an event), stable
                                                      1998). Initial screenings with a self-report
(the causes of an event remain constant), and
                                                      measure should typically be followed by an in-
global (event outcomes impact all areas of life)
                                                      depth diagnostic interview.
attributions for failure. In contrast, they attrib-
ute success to external (caused by others), un-
stable (causes of events are transitory), and
                                                      Diagnostic Interviews
specific (situation-specific) causes.
                                                      In-depth diagnostic interviews are used to ac-
                                                      curately evaluate the number and severity of
ASSESSMENT OF DEPRESSION                              depressive and other (e.g., anxiety) symptoms
                                                      in children and adolescents. Some of the more
Assessment of childhood and adolescent de-            common semistructured interviews include
pression should include information from mul-         the Interview Schedule for Children (ISC;
tiple sources (e.g., parent, child, and teacher).     Kovacs, 1985b), the Child Assessment Sched-
The specific number of sources needed for ac-         ule (CAS; Hodges, Kline, Stern, Cytryn, &
curate assessment depends on the age of the           McKnew, 1982), and the Schedule for Affective
child. Young children may not be able to pro-         Disorders and Schizophrenia for Children (K-
vide a full clinical picture of their symptoms;       SADS; Puig-Antich & Chambers, 1978). Semi-
thus, information obtained from parents and           structured interviews allow counselors some
teachers is typically more necessary than it          flexibility in assessing the symptoms of de-
may be with older children. Adolescents usu-          pression as well as other disorders. Most of the
ally provide a more accurate picture of their         diagnostic interviews mentioned above assess
own depressive symptoms than their parents            for a wide range of other disorders (e.g., anxi-
do. In fact, agreement between parent and ado-        ety, PTSD) in addition to depression. An accu-
lescent report has been found to be low when          rate diagnostic assessment of the child or
diagnosing Major Depressive Disorder in ado-          adolescent is important when considering the
lescents; typically, parents underreport de-          high comorbidity of depression with other dis-
pressive symptoms as compared to adolescents          orders (Rohde, Lewinsohn, & Seeley, 1991). In
(Lewinsohn, Rohde, et al., 1998). Thus, coun-         choosing which interview to administer it is
selors should not rely on parent report alone in      important to consider the age of the child as
diagnosing depression.                                well as the psychometric properties of the
    28 • RECOMMENDATIONS FOR CHILDREN AND ADOLESCENTS WITH DEPRESSION                          201

instrument. Counselors are encouraged to           treatment and alleviation of depression in
consult the specific reference(s) for each diag-   adolescents. In young children, however, a
nostic instrument to determine the appropri-       cognitive focus may not be as effective because
ateness for a given client.                        higher-order thinking may not have de-
                                                   veloped yet.
Diagnosis                                             Cognitive-behavioral treatments for de-
                                                   pression flow directly from the cognitive and
The Diagnostic and Statistical Manual of Mental    behavioral models described earlier. For ex-
Disorders, fourth edition (DSM-IV; American        ample, Beck and colleagues (1979) developed
Psychiatric Association, 2000) has added           a therapy with both behavioral and cognitive
precision to the diagnosis of depression in        components designed to reduce automatic
childhood and adolescence from previous edi-       negative cognition with the goal of challeng-
tions. The DSM-IV presents differential symp-      ing the assumptions that maintain these
toms of adolescent depression from symptoms        faulty cognitions. Because depressed clients
commonly experienced by adults. For exam-          often have difficulty utilizing cognitive tasks,
ple, children commonly display irritable mood      behavioral strategies should be used first in
rather than depressed mood, somatic com-           the therapeutic process. These strategies in-
plaints, and social withdrawal, whereas            clude scheduling pleasant activities, relax-
depressed adolescents typically display psy-       ation training, graduated task assignments,
chomotor retardation and hypersomnia. Chil-        social skills training, and behavioral re-
dren may also display depressive symptoms in       hearsal (Reinecke et al., 1998).
conjunction with disruptive behavior disor-           Certain behavioral strategies increase an
ders (e.g., attention-deficit, anxiety), whereas   individual’s activity level and therefore the
depression in adolescents is commonly associ-      frequency of potentially rewarding activities.
ated with disruptive behavior disorders as         During depression, there is a tendency to
well as substance-related disorders and eating     withdraw from pleasurable activities and in-
disorders (Miller-Johnson et al., 1998). Rates     teractions with others. Behavioral strategies
of depression are relatively equal between         can be used to directly address withdrawal
boys and girls, but during adolescence, fe-        behaviors and encourage children and adoles-
males have increased rates of depression           cents to engage in more pleasurable activities
closely paralleling the gender differences         such as increasing the number of daily enjoy-
found in adulthood (American Psychiatric As-       able activities engaged in. Lewinsohn, Clarke,
sociation, 2000).                                  and Rohde (1994), for example, describe using
                                                   an instrument called the Pleasant Events
                                                   Schedule (PES; MacPhillamy & Lewinsohn,
TREATMENT STRATEGIES FOR CHILDREN
                                                   1982) with depressed adolescents in a way
AND ADOLESCENTS
                                                   that will help them increase the frequency of
                                                   pleasurable activities.
Individual
                                                      After these strategies are successfully uti-
Frequently, individual approaches involve both     lized, emphasis is moved to cognitive inter-
individual and family sessions, with the focus     ventions that emphasize identifying, testing,
remaining on the depressed child or adoles-        and modifying cognitive distortions. Strate-
cent. We focus on cognitive-behavioral ap-         gies that have been successfully used include
proaches here because they have demonstrated       (1) recognizing the connections among cogni-
effectiveness. For instance, Reinecke, Ryan,       tion, affect, and behavior; (2) monitoring neg-
and DuBois (1998) conducted a meta-analysis        ative automatic thoughts; (3) examining
of cognitive-behavioral therapy for depression     evidence related to distorted automatic cogni-
and dysphoria. All of the 24 studies they ana-     tion; (4) substituting more realistic interpre-
lyzed employed cognitive-behavioral interven-      tations for distorted cognitions; (5) learning
tions and demonstrated positive results in the     to identify and modify irrational beliefs;
202     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

(6) altering biased attentional processes;           depression and address the underlying con-
(7) affect regulation; and (8) impulse control       flict associated with the depression. Examples
(Brent et al., 1996).                                of techniques used in this approach include ex-
    Another cognitive-behavioral treatment           ploratory questioning, linking affect and
approach for children and adolescents is the         events, clarifying conflicts and communication
application of Rational-Emotive Behavior             patterns, and behavior modification strategies.
Therapy (REBT) developed by Albert Ellis             This approach has received promising empiri-
(Vernon, 1999). REBT was originally devel-           cal support (Mufson & Fairbanks, 1996).
oped for adults but has also been used with              Pharmacological interventions are, in some
children and adolescents suffering from a            cases, required with depressed clients. Med-
number of disorders including depression.            ication usage for depressed youth has fol-
Vernon described the major theoretical ideas         lowed the trend of adult research. Since the
behind REBT: (1) Individuals develop beliefs         1960s, tricyclic antidepressants (TCAs) have
(i.e., rational or irrational) and subsequent        been prescribed for young patients, although
emotions and behaviors regarding events that         the effectiveness of antidepressants for chil-
impede their progress toward a goal; (2) an in-      dren and adolescents has not been established
dividual’s irrational beliefs (e.g., “I fail at      through controlled research (Brent et al.,
everything”) must be challenged by the coun-         1996). The majority of randomized controlled
selor; and (3) comprehensive therapy must            trials (RCTs) conducted with children and
focus on long-term change (i.e., core irrational     adolescents with a depressive disorder have
beliefs) instead of a quick fix. For more spe-       used TCAs as the psychopharmacological
cific recommendations for implementing               treatment (Birmaher, 1998). Another class of
REBT with children and adolescents suffering         antidepressant medication having fewer side
from depression, see Vernon.                         effects, as compared to TCAs, is the class of
    In some clinical settings (e.g., schools, man-   drugs known as selective serotonin reuptake
aged care) counselors may be limited to a few        inhibitors (SSRIs). Birmaher found that very
sessions in which to treat children and adoles-      few RCTs have tested the efficacy of SSRIs for
cents with depression. In such circumstances,        the treatment of depression in children and
a brief counseling model should be used. Lit-        adolescents. One of the SSRIs, fluoxene, has
trell and Zinck (1999) describe one brief model      been found to be effective for the treatment of
that has been used with children and adoles-         depression in one RCT (Emslie et al., 1997).
cents. Their approach rests on eight character-      Birmaher recommends using SSRIs when the
istics: being time-limited, solution-focused,        child or adolescent suffers from a type of de-
action-based, socially interactive, detail-ori-      pression not easily treated with counseling or
ented, humor-eliciting, developmentally atten-       therapy. See also Kutcher (1998) for further
tive, and relationship-based. This approach          information about pharmacological interven-
can also be implemented with other brief ther-       tions for depression.
apy modalities.
    Another individual approach that has
                                                     Family
demonstrated positive results in alleviating
depression in adolescents is interpersonal psy-      The role of the family in the successful treat-
chotherapy (IPT). This therapy conceptualizes        ment of the depressed child or adolescent is
depression as conflict taking place in the con-      crucial. Family counseling has been shown to
text of interpersonal relationships (Mufson &        be very important in the effective treatment of
Fairbanks, 1996). There are five areas that form     childhood disorders, in part due to the exten-
the problem areas and treatment goals in IPT:        sive influence families have over young chil-
grief, interpersonal role disputes, role transi-     dren compared with adolescents (Nichols &
tions, interpersonal deficits, and membership        Schwartz, 1995). Counselors using only an in-
in a single-parent family (this is a modification    dividually based intervention strategy may,
for use with adolescents). Goals are to reduce       in fact, be doomed to failure because from
     28 • RECOMMENDATIONS FOR CHILDREN AND ADOLESCENTS WITH DEPRESSION                                  203

this perspective the entire family system            specific grade-level interventions targeted to
needs to change. Counselors must be pre-             the young person’s developmental level. Topics
pared to work with all family members, espe-         such as self-acceptance, feelings, behaviors,
cially parents who may also suffer from an           problem solving, decision making, and inter-
affective disorder or who may have marital           personal relationships are addressed. In addi-
conflict. Concurrent family therapy is, thus,        tion, Lewinsohn, Clarke, and Rohde (1994)
nearly always indicated in working with de-          described an eight-week cognitive-behavioral
pressed children and adolescents (Nichols &          group intervention titled Adolescent Coping
Schwartz, 1995).                                     with Depression Course (CWD-A). Success for
   In many circumstances, parent training and        the CWD-A group intervention has been
education can benefit the family and help pre-       demonstrated in clinical settings, and because
vent depression and other problems. Work-            its individual sessions are presented in a
shops in parent training can be particularly         classlike manner, it may be adaptable to school
useful and cost-effective, especially those that     settings (Lewinsohn, Clarke, et al., 1994). Al-
focus on developing communication skills, en-        though the results for group-based inter-
hancing family interactions, and sharing infor-      ventions for depression are promising, more
mation about issues (such as birth control,          research on group-based intervention con-
signs of drug use). In families with greater         ducted in school settings is needed.
dysfunction, therapeutic programs attending
to child abuse and neglect, parental dysfunc-
tion, and family violence may also be ex-            SUMMARY
tremely beneficial.
                                                     Depression is a significant and complicated
School Settings                                      mental health problem among children and
                                                     adolescents. Its manifestation in childhood
The occurrence of depression among children          varies but in adolescence is more similar to
and adolescents has increased in recent years        that found in adulthood. Current research
and is due in part to environmental stressors,       supports several treatment approaches as
in which schools play a major role. This sup-        being similarly successful in remitting de-
ports the need for early prevention and inter-       pression. Readers are encouraged to refer to
vention in the school setting. School prevention     the references for this chapter for further
and treatment should include a mixture of af-        reading and more detailed coverage of each
fective, cognitive, and behavioral strategies that   of the areas reviewed. As indicated by much
focus on issues such as self-acceptance, prob-       of the treatment literature cited herein, any
lem solving and decision making, and social          successful intervention for child and adoles-
skills and interpersonal relationships (Vernon,      cent depression must focus on the whole
1989). Group interventions are central to many       ecology of a young person’s life—school,
school-based prevention programs because of          family, community, and individual interven-
their ability to reach a large number of children    tions—to be fully successful in reaching out
and their relative cost-effectiveness, adaptabil-    to and helping young people who suffer from
ity to the classroom format, and usefulness for      depression.
training skills.
   School-based small group intervention pro-
grams for depression and other psychosocial          References
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                                                     American Psychiatric Association. (2000). Diagnos-
ated, but existing outcome studies indicate              tic and statistical manual of mental disorders (4th
some positive results. For example, Vernon               ed., text rev.). Washington, DC: Author.
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tion curriculum based on REBT. This program              (1979). Cognitive therapy of depression. New
targets thoughts, affect, and behavior and has           York: Guilford Press.
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    IL: Research Press.




                    COUNSELING INTERVENTIONS
      29            FOR CHILDREN WITH
                    DISRUPTIVE BEHAVIORS


                    John Sommers-Flanagan, Rita Sommers-Flanagan,
                    and Charles Palmer

In this chapter, we review treatment approaches           youth who exhibit disruptive behavior disor-
for young people referred for counseling be-              ders can be a complex and challenging process.
cause of disruptive behavior—children whose               To provide effective treatment, counselors
main symptoms include misconduct, hostility,              should educate themselves regarding factors
aggression, impulsivity, defiance, and disrup-            that can influence the diagnosis and treatment
tive behaviors. These symptoms are commonly               of disruptive youth (see House, Chapter 30). A
associated with Conduct Disorder and Opposi-              number of these factors are:
tional Defiant Disorder (American Psychiatric
Association, 2000). Although children diag-               • Diagnostic comorbidity. The existence of two
nosed with Attention-Deficit/Hyperactivity                  or more diagnostic entities within a single
Disorder (ADHD) and clinical depression also                individual is very common among youth
regularly exhibit these challenging behavior                who display disruptive behaviors; for exam-
patterns (Knox, King, Hanna, Logan, & Ghazi-                ple, it is estimated that Conduct Disorder
uddin, 2000), specific treatments for children              and ADHD coexist 45% to 70% of the time,
and adolescents diagnosed with ADHD and de-                 and Conduct Disorder and Oppositional De-
pression are covered elsewhere in this source-              fiant Disorder coexist in 84% to 96% of cases
book (see Chapter 26 for information pertaining             (Hinshaw, Lahey, & Hart, 1993; Offord,
to treatment for youth diagnosed with ADHD                  Boyle, & Racine, 1991). Additionally, the co-
and Chapter 28 for treatments for depressed                 existence of Posttraumatic Stress Disorder,
children).                                                  substance abuse disorders, learning disor-
                                                            ders, Reactive Attachment Disorder, anxiety
                                                            disorders, and depression is surprisingly
IDENTIFICATION AND                                          high among misbehaving youth (Carrion
TERMINOLOGY ISSUES                                          & Steiner, 2000; Sommers-Flanagan &
                                                            Sommers-Flanagan, 1998).
As one might guess from the introductory                  • Client deceit. Young clients who engage in
paragraph, assigning psychiatric diagnoses to               disruptive behaviors frequently minimize,
206      PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

    deny, or blatantly lie to their counselors       hypnosis, biofeedback, and psychotropic med-
    about their misbehavior; therefore, it is in-    ications (Bandoroff & Scherer, 1994; Kazdin,
    appropriate to work with these clients           1996). Most professionals acknowledge that it
    without obtaining information about their        is very difficult to provide effective treatment
    lives outside the counseling office.             for disruptive young clients (Bernstein, 1996;
•   Parent and teacher misinformation. Parents       Church, 1994; Kazdin & Wassell, 2000; Meeks,
    and teachers may be uninformed or misin-         1980).
    formed when it comes to specifying the
    details of young clients’ behavior; once
                                                     Dealing with Client and Parent Resistance
    again, obtaining information from diver-
    gent sources is crucial.                         Children and adolescents who behave disrup-
•   Counselor countertransference. While work-       tively often strain their relationships with
    ing with disruptive youth, counselors may        many important adults (e.g., parents, teach-
    be emotionally affected in ways that can         ers, probation officers). Consequently, when
    interfere with therapeutic objectivity.          these young clients arrive at the counselor’s
    (Some writers have referred to counseling        office, it is not usually because of their own
    with difficult adolescents as “blood sport”;     desire for personal change, but instead be-
    Trepper, 1991, p. ix, which suggests that        cause some adult has determined (or hopes
    adversarial relationships between young          fervently) that they might benefit from coun-
    clients and their counselors can develop).       seling. Thus, counselors may be immediately
•   Confounding cultural and situational factors.    confronted with a disinterested and unmoti-
    Often, disruptive behavior disorders are as-     vated client. Most researchers and writers
    sociated with difficult living conditions        stress that, for treatment with disruptive
    such as large family size, poverty, over-        young clients to be effective, counselors must
    crowding, homelessness, parental absence         somehow develop and maintain a positive
    or abuse, transportation problems, poor or       therapeutic alliance with the client. For exam-
    inadequate housing, and less-than-optimal        ple, Hanna, Hanna, and Keys (1999) state: “A
    school settings (Canino & Spurlock, 1994;        counseling technique performed without a
    Kazdin, 1998).                                   properly established empathic and trusting
•   Biogenetic conditions. Although whether          relationship seems to many defiant adoles-
    heredity or biogenetic factors play a strong     cents to be a threat to their integrity, and just
    role in Conduct Disorder and Oppositional        another covert or overt adult attempt at ma-
    Defiant Disorder is controversial, research      nipulation” (p. 396).
    clearly points to the importance of bio-            To further magnify the problem, research
    genetic conditions (e.g., lead toxicity, brain   has shown that parents of children who are
    injury) in causing or contributing to impul-     most seriously disturbed are often the most re-
    sive, antisocial, and disruptive behavior.       sistant to participating in treatment (Reid,
                                                     1993). These parents typically drop off their
                                                     children for counseling, hoping that the coun-
MAJOR THEORETICAL, RESEARCH, AND                     selor will quickly and efficiently “fix” their
PRACTICE PRINCIPLES                                  child. When parental resistance to counseling is
                                                     high, it may stem from chronic frustration with
There are many different approaches to treat-        their child’s behavior, apathy and/or depres-
ing youth with disruptive behavior problems.         sion, substance abuse, poverty, or other family
These approaches include, but are not limited        dynamics associated with disengagement.
to, family counseling, group and classroom in-          The key point is that for treatment to pro-
terventions, parent training, and individual-        ceed with this particular population, parent
ized treatment strategies such as behavioral         and child resistance must be addressed. This
and cognitive-behavioral counseling, residen-        means that counselors should consider using
tial, hospital, and wilderness-based programs,       strategies, incentives, playful activities, humor,
    29 • COUNSELING INTERVENTIONS FOR CHILDREN WITH DISRUPTIVE BEHAVIORS                        207

and reassurance to reduce resistance and en-        approach involves directly teaching parents
gage parents and children in treatment.             to appropriately reinforce prosocial behavior,
                                                    use effective discipline techniques, provide
Empirically Supported Treatment Approaches          adequate supervision and monitoring of chil-
                                                    dren’s behavior, communicate more effec-
Despite difficulties engaging disruptive chil-      tively, model more appropriate behaviors, and
dren and their parents in counseling, several       cope with difficult situations, such as divorce
treatments hold promise for working effec-          or death of a family member (Danforth, 1999).
tively with this population. These approaches       Currently, at least two parent-focused treat-
can be divided into three groups: parent-fo-        ments show promising empirical outcomes
cused treatments, family-focused treatments,        with disruptive behavior disordered children.
and child-focused treatments. Although this         These approaches include videotape modeling
chapter primarily addresses child-focused           (Webster-Stratton, 1996) and parent manage-
treatments, we first briefly review parent-         ment training (Kazdin & Wassell, 2000).
and family-focused treatment approaches
                                                    Family-Focused Treatments. Family therapists
that have garnered empirical support for re-
                                                    (Szapocznik, Kurtines, Santiseteban, & Rio,
ducing children’s disruptive behaviors.
                                                    1990) argue that interventions for disruptive
   A recent meta-analysis indicated that indi-
                                                    children must include their families. There
vidual cognitive-behavioral treatments are
                                                    are a number of good reasons for this view.
only marginally effective with young children
                                                    Interventions directed toward families avoid
(Bennett & Gibbons, 2000). This is probably be-
                                                    identifying and labeling the child as the pri-
cause younger children are less cognitively de-
                                                    mary problem and help illustrate that a
veloped and generally more influenced by
                                                    child’s difficult behaviors can be a part of the
their family systems. Consequently, the fol-
                                                    overall family system dynamics. Family coun-
lowing parent and family approaches to treat-
                                                    selors can help identify family patterns that
ing children who behave disruptively are
                                                    may be contributing to the child’s behaviors
especially recommended when counselors are
                                                    and help the family find alternative ways to
working with young children.
                                                    cope and change.
Parent-Focused Treatments. Parent-focused psy-         Family therapy is a demanding specialty.
choeducational interventions can be effective       Frequently, family therapy, even more rigidly
when parents cooperate with treatment.              than individual therapy, is defined in terms of
Parent-focused treatments have their roots in       specific theoretical frameworks. To compe-
social learning theory. This perspective sug-       tently practice family therapy, extensive edu-
gests that children initially learn aggressive      cation and training in a particular theoretical
and defiant behavior patterns within their          model may be necessary. Currently, there are
family context (Patterson, 1982): “The pio-         two behavioral systems approaches to family
neering research of Patterson and others has        therapy that, thus far, have gained empirical
found that parents of children with                 support: functional family therapy (Alexander
conduct disorders exhibit fewer positive be-        & Parsons, 1982; Morris, Alexander, & Wal-
haviors, use more violent disciplinary tech-        dron, 1988) and multisystemic family therapy
niques, are more critical, more permissive,         (Henggeler, Melton, & Smith, 1992).
less likely to monitor their children’s behav-
iors and more likely to reinforce inappropri-
ate behaviors while ignoring, or even               INDIVIDUAL TREATMENTS FOR YOUTH
punishing, prosocial behaviors” (Webster-           WITH DISRUPTIVE BEHAVIORS: PRINCIPLES
Stratton, 1996, p. 437).                            AND PROCEDURES
   Parent-focused approaches seek to modify
children’s disruptive behaviors by changing         As noted previously, individual treatments
family interactions from coercive and aggres-       for children with disruptive behaviors are
sive to positive and prosocial. Essentially, this   more clinically indicated for adolescents or
208     PART III • TREATMENT OF CHILDREN WITH MENTAL AND EMOTIONAL DISORDERS

older children (Bennett & Gibbons, 2000). The       • Get out of the office.
following principles and procedures are ac-         • Use a variety of media to allow the client
knowledged as having general theoretical              to express what is inside without having to
support, as well as limited empirical support.        rely solely on verbal skills.
                                                    • Let clients know how much you have
                                                      learned from their sessions.
Engagement
                                                    • Treat shocking statements with equanim-
Virtually all approaches to working individu-         ity and instant reframes.
ally with disruptive behavior disordered youth      • Avoid any unnecessary insistence on being
emphasize the importance of addressing initial        verbally respected.
client reluctance or resistance, forming a thera-
peutic alliance, and engaging clients in poten-        Third, as we discuss in our book, Tough
tially therapeutic interactions (Bernstein, 1996;   Kids, Cool Counseling (Sommers-Flanagan &
Hanna & Hunt, 1999; Meeks, 1980; Sommers-           Sommers-Flanagan, 1997), therapeutic al-
Flanagan & Sommers-Flanagan, 1995, 1997).           liances with reluctant young clients can be
Strategies for reducing resistance, building an     built partly by implementing specific rela-
alliance, and engaging young clients in coun-       tionship-building techniques: “Interesting
seling can generally be divided into three cate-    techniques can overcome the youth’s initial
gories. First, many clinicians advocate using       resistance to forming a therapy relationship
basic Rogerian relationship variables (congru-      and to engaging in therapeutic procedures. In
ence, unconditional positive regard, and accu-      fact, with young clients, interesting tech-
rate empathy; Rogers, 1957) to enhance the          niques may enhance the therapeutic alliance
counselor-client therapeutic alliance. For ex-      regardless of the particular technique’s im-
ample, Bernstein (1996) recommends that             pact on symptom reduction. Our point is that
counselors learn about adolescent culture so        simply doing something interesting together with
that they can quickly express interest and re-      young clients often enhances the counseling
spect to defiant adolescents: “I saw a young        relationship” (p. 35). Specifically, we recom-
man who was rather quiet and indifferent dur-       mend that counselors have a wide range of
ing our first meeting. I noted that he was wear-    potentially therapeutic activities available for
ing a Guns and Roses tee shirt and recalled         use with active and disruptive young clients
something I had recently read about the rock        (e.g., the hand-pushing game, drawing to-
group. ‘Did you hear what happened at the           gether, arm wrestling, sharing jokes and rid-
Guns and Roses concert in St. Louis last week?’     dles, passing notes; see Sommers-Flanagan &
I queried. ‘No, what?’ he quickly responded.        Sommers-Flanagan, 1997).
Suddenly I had his undivided attention”
(pp. 41– 42).
                                                    Cognitive Behavioral
   Second, many clinicians recommend modi-
                                                    Problem-Solving Approaches
fying structural, strategic, or situational ther-
apy components to make sitting and talking          Much of the treatment literature for children
more comfortable for adolescents (Bernstein,        with disruptive behavior disorders has focused
1996). In their article “Fifty Strategies for       on how children can be taught to increase their
Counseling Defiant Adolescents,” Hanna              self-control through interpersonal cognitive
et al. (1999) describe numerous structural and      problem-solving processes (e.g., means-end
strategic modifications that can help young         thinking, consequential thinking, and generat-
clients talk to and interact with counselors        ing cognitive and/or behavioral alternatives;
more comfortably. These include:                    Spivack & Shure, 1982). Additionally, most
                                                    treatment approaches integrate behavioral rein-
• Offer a snack.                                    forcement and self-reinforcement into their
• Avoid desks.                                      programs. The goal is to help impulsive and dis-
• Allow clients to occupy their hands while         ruptive children engage in constructive prob-
  talking.                                          lem-solving strategies rather than continuing to
      29 • COUNSELING INTERVENTIONS FOR CHILDREN WITH DISRUPTIVE BEHAVIORS                      209

rely on impulsive and reactive interpersonal be-   procedures described below are important
haviors. For example, in his problem-solving       because adolescents can be very sensitive to
skills training program, Kazdin (1996) reports     rejection and parental alignment (Sommers-
teaching children the following five sequential    Flanagan & Sommers-Flanagan, 1997).
problem-solving and self-instructional steps:         Family meetings are sessions during
                                                   which all relevant family members are in at-
1.   What am I supposed to do?                     tendance. These meetings are implemented
2.   I have to look at all my possibilities.       within the context of the young client’s indi-
3.   I had better concentrate and focus in.        vidual therapy. The emphasis in family meet-
4.   I need to make a choice.                      ings is on parent-child communication and
5.   I did a good job; or, Oh, I made a mistake.   parent training, using the child or children
     (p. 383)                                      as assistants. Family meetings use a child
                                                   empowerment model wherein children have
   Emphasizing self-control strategies with        input regarding appropriate limits, conse-
impulsive and disruptive adolescents capital-      quences, behavioral choices, and so on.
izes on strong autonomy and individuation             When conducting family meetings, we uti-
striving during adolescence (Church, 1994). To     lize the following procedural guidelines:
maximize their effectiveness, counselors can
make statements that place therapeutic success     1. The therapist and child meet prior to the
firmly within the youth’s control. For example,       family meeting to establish a plan regard-
“Okay, let’s talk about strategies for how you        ing WHAT will be discussed during the fam-
can get more of what you want out of life”            ily meeting and HOW it will be discussed.
(Sommers-Flanagan & Sommers-Flanagan,              2. Therapist and child have established goals
1997, p. 115).                                        for the family meeting. Additionally, they
                                                      may have made predictions regarding how
                                                      the parents will respond to topics that are to
Other Treatment Approaches
                                                      be discussed and they may have made con-
In addition to traditional problem